Practical Manual of Hysteroscopy 10

Enlan Xia
Editor
Practical Manual of
Hysteroscopy
123
Practical Manual of Hysteroscopy
Enlan Xia
Editor
Practical Manual
of Hysteroscopy
Editor
Enlan Xia
Hysteroscopy Center
Fuxing Hospital, Capital Medical University
Beijing, China
ISBN 978-981-19-1331-0 ISBN 978-981-19-1332-7 (eBook)

https://doi.org/10.1007/978-981-19-1332-7
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Foreword to the Third Edition
It has been 6 years since the publication of the second edition of Practical Manual of
Hysteroscopy. During this period, hysteroscopy has been widely practiced in clinics and has
developed rapidly. Hysteroscopic diagnosis with localized biopsy is the golden standard for
modern diagnosis of intrauterine pathologies. Hysteroscopic surgery has been widely accepted
because of its low traumatic ratio, high potency ratio, excellent efficacy, and irreplaceability. It
has been described as a model of successful modern minimal traumatic surgery and has been
one of four main gynecological surgeries which are commonly used (hysteroscopy, laparos-
copy, laparotomy, and transvaginal surgery). By retrieving hysteroscopic-related literatures
published in these 6 years, 7925 papers were found from China National Knowledge
Infrastructure (CNKI), and 1520 papers from MEDLINE, which showed active academic
activities and wide applications in the field of hysteroscopy. By writing the third edition of An
Atlas of Hysteroscopy, we undergo some supplement and revision according to the advance-
ments of basic research and clinical application at home and abroad in recent years, combining
with our own practical experience in our center. We hope that this book will be of great benefit
to gynecologists in studying, grasping, advocating, and even teaching hysteroscopic
technique.
In total, there are 16 chapters, more than 380,000 words, and 760 pictures included in this
book. The revised item is Sect. 2.4, Chap. 2—Cleaning, Sterilization, and Maintenance of
Hysteroscopic Instruments. It introduced the disinfection of hysteroscopic instruments in the
second edition, including bacteriostasis and sterilization. In the third edition, the sterilization
of hysteroscopic instruments is described, as bacteriostasis was obsoleted. The contents added
include: (1) A new classification of uterine malformation: there is a new classification system
of female genital malformations and jointly published by European Society of Human
Reproduction and Embryology (ESHRE) and European Society for Gynecological Endoscopy
(ESGE). This system is simple and memorable with high practicability and achieves the
approval of most clinical gynecologists. (2) Metroplasty for a rare form of uterine malforma-
tion: it includes Robert uterus, complete bicornuate uterus, unicornuate uterus, and “T”-shaped
uterus. Transcervical uterine incision (TCUI) excises the excessive myometrial tissues on uter-
ine lateral walls or cuts the thickened myometrium on one or two lateral walls so as to improve
the shape of the uterus, enlarge the uterine cavity, relieve intrauterine pressure, improve endo-
metrial blood supply to facilitate the implantation of fertilized eggs, prevent miscarriage, and
improve the reproductive outcomes. Combined hysteroscopic and laparoscopic metroplasty
for complete bicornuate uterus is performed under laparoscopic monitoring, the hysteroscopic
electrode is used to incise the intrauterine plate and the fundus to serosal layer, causing artifi-
cial perforation. Then transversely incise the full layer of the fundus and suture the incised wall
longitudinally by laparoscopy to achieve a normal shape cavity and increase the possibility of
fertility. Some infertile women who were treated in our center for these malformations have
delivered healthy infants after metroplasty. (3) The advancement of diagnosing and treating
adenomyosis: it includes the findings under hysteroscopy, which can make the diagnosis in
early stage; hysteroscopic surgery for cystic adenomyosis can replace the removal of uterine
v
vi Foreword to the Third Edition
corpus or partial uterus, and obtain the possibility of fertility; the joint application of
phloroglucinol dehydrate, narrow band imaging (NBI) hysteroscopy, levonorgestrel-releasing
intrauterine system (LNG-IUS), GnRH analog, and hysteroscopic endometrial resection for
treatment of adenomyosis, which can enhance the effect of GnRH-a and TCRE and meet the
patients’ desire to preserve the uterus. (4) Transcervical resection of diffuse uterine leiomyo-
matosis (DUL): after operation, the endometrium can recover within 2 to 3 months, the
improvement of menstruation achieved 93.5%, the recurrence rate was 32.3%, and some
patients obtained conception and birth. (5) The prevention of adhesion recurrence after trans-
cervical resection of intrauterine adhesions (TCRA): adjunctive therapies such as postopera-
tive hormone treatment, intrauterine placement of balloon catheter, insertion of human amnion
graft, instillation of auto-cross-linked HA (ACP) gel, application of prophylactic antibiotics,
and second-look hysteroscopy have been discussed. (6) NBI hysteroscopy: NBI utilizes the
light absorption properties of hemoglobin at a certain wavelength to improve the contrast of
blood vessels in superficial endometrial layer and well display the mini-structure of the endo-
metrium; therefore it could facilitate the identification of endometrial atypical lesions. It can
be used in hysteroscopy so that it can discover the endometrial lesions in early stage, make
localized biopsy, and increase the discovery rate of precancerous lesion and endometrial can-
cer. (7) Pretreatment of cervix with phloroglucinol: it is a pro-muscle non-atropine non-
papaverine class pure smooth muscle antispasmodic agent, which is applied in hysteroscopic
examination and operation, and has analgesic and cervical looseness effects. (8) Paradoxical
emboli caused by venous air embolism with gas emboli entering the left heart: in 2008,
Rademaker et al. first reported on one case of fatal paradoxical gas embolism with gas emboli
entering the left heart from the right heart through atrial septal defect, open foramen ovale,
pulmonary arterio-venous malformations, or arterio-venous fistula.
I would like to express my acknowledgment to all people who provided us with generous
help during my compilation of this book, such as Li Jing and Zhong Qin from Scientific
Research Office of Fuxing Hospital; Mr. Liu Xuegang and Mr. He Baijiang, who are former
managers of Endoscope Marketing Department, Olympus (Beijing) Ltd.; and Mrs. Zhang
Zhen from Endoscope Marketing Department, Olympus (Beijing) Ltd. I would also like to
thank all colleagues, advanced training physicians, and graduate students in our department for
their cooperation!
Any mistake and deficiency due to our limited experience will hopefully be pointed out and
forgiven!
Beijing, China Enlan Xia

August 31, 2014
Foreword to the Second Edition
With the development of a holistic concept of surgical treatment in the 1970s, an aggregative
indicator, including patients’ physiological condition, social activities, and mental outlook, has
become an important indicator for the assessment of surgical outcomes and a research object.
The introduction of advanced technology prompts the minimally invasive concept and mini-
mally invasive surgery to develop gradually and boom. As an important part of the minimally
invasive surgery, the development of hysteroscopy has changed the diagnosis and treatment
pattern of the traditional gynecological diseases, which can not only bring about the benefits
of minimally invasive surgery, including less trauma, less intraoperative bleeding, few compli-
cations, low cost, short hospitalization, and quick recovery, but also preserve the uterus,
improve the reproductive prognosis, and cope skillfully with such intractable conditions as
vaginal foreign body, cervical/intrauterine lesions, asymmetric septate uterus, and oblique
vaginal septum, which is hard to deal with even in an open surgery. Hysteroscopy can be used
to diagnose almost all the intrauterine benign diseases like intrauterine lesions, dysfunctional
uterine bleeding, submucous myoma, septal deformities, endometrial polyps, intrauterine
adhesions, removal of foreign bodies, et al. and can replace, even be superior to traditional
open surgery. So hysteroscopy has become a revolutionary event and a milestone in the devel-
opmental history of gynecology. Hysteroscopic technology is characterized by its minimal
invasiveness, which offers doctors a golden platform to open up new fields of application, and
thus making their professional career prolonged and more colorful.
Over the past 10 years, there has been a rapid development of hysteroscopic technology in
our country, the gap with the international advanced level has been narrowed ceaselessly, and
both the hysteroscopic philosophy and technique have been greatly improved. Encouraged by
Henan Science and Technology Press, 5 years ago, we edited a book An Atlas of Hysteroscopy
together with experts in hysteroscopy at home and abroad, and this book has been widely
appreciated by readers.
Time slipped away little by little, and 5 more years passed away unnoticed. There have been
a lot of new advances in hysteroscopic technology over time. Firstly, the improved instruments
and devices—the integrated hysteroscope has integrated the double advantages of flexible and
rigid hysteroscope, which can not only further relieve patients’ pains and improve the thera-
peutic effects but also make doctors feel more intuitively the motive force of the progress in
instruments on the development of therapeutic techniques and clinical treatment. Secondly, the
application of transvaginal endoscope has turned hysteroscopic examination into a noninvasive
procedure. Hysteroscopy has been widely used in the diagnosis and treatment of infertility, and
a consensus has been reached that hysteroscopic surgical treatment for intrauterine abnormali-
ties is superior in reproductive prognosis to traditional surgery. In 2006, plasma bipolar resec-
toscope came into being in China. The use of bipolar resectoscope with saline as irrigation
fluid is unlikely to cause hyponatremia and safer than monopolar resectoscope. A second look
following resection of severe intrauterine adhesions may prevent reformation of adhesion and
multiple surgeries and can restore the normal morphology of uterine cavity, which has been
widely accepted. And the postoperative pregnancy rate may reach 28.7%–53.6%. With the
wide application of operative hysteroscopy and accumulation of experiences, it has become a
safe and minimally invasive surgery with excellent prognosis and few complications and is
vii
viii Foreword to the Second Edition
easy to learn. There has been a change in the sequence of complication occurrence, the risk of
false passage and uterine perforation rises to be the first. Gas embolism is the most dangerous
complication and can be prevented if strict precautions are taken. Second-generation endome-
trial ablation procedure is simpler and quicker than first-generation monopolar electroresec-
tion, but similar in satisfaction rate and the effect of reducing blood loss. And complications
occur after both first-generation and second-generation endometrial ablation. On the occasion
of the reprinting of this book, the above advances in hysteroscopy will be expatiated in the
related chapters for readers.
I dedicate this book to my first teacher in hysteroscopy Prof. Lin Yuanying and also to Prof.
Song Hongzhao, Prof. Zhou Suwen, Prof. Li Zixin, and Prof. Liu Zongtang, who gave me a lot
of support and encouragement. And my most sincere gratitude goes to Mr. Liu Xuegang, Mr.
He Baijiang, Mrs. Li Jihong, Mrs. Liu Ya’an, and Mrs. Zhang Meng from Japan’s Olympus
Corp., who helped me in collecting images and providing equipment and technical support.
December 20, 2008 Enlan Xia

Foreword to the First Edition
The application of diagnostic hysteroscopy and operative hysteroscopy and other new tech-
niques provides an economic, feasible, simple, and effective way in the clinical treatment of
intrauterine benign lesions. At present, diagnostic hysteroscopy is the gold standard for diag-
nosing intrauterine lesions and is gradually replacing the blind diagnostic curettage. And oper-
ative hysteroscopy has become the optimal surgical procedure in treating dysfunctional uterine
bleeding and also the standard surgical procedure for the treatment of uterine septum and the
gold standard for treating endometrial polyps. A great deal of follow-up study has confirmed
the efficacy of hysteroscopic electroresection in the treatment of benign intrauterine lesions.
Operative hysteroscopy has the minimal ratio of internal trauma and the maximal ratio of cost
and effect, so it is called a model of successful minimally invasive surgery. In our country, as
the clinical application of hysteroscopic diagnosis and therapeutics has been popularized day
by day, the hysteroscopic technique has been applied more extensively in recent years.
Tracing back to the developmental history of hysteroscopic techniques in China, we could
not forget the late specialist in obstetrics and gynecology, Prof. Lin Yuanying, PhD. He was the
first person to advocate the development of hysteroscopy in China, who had ever worked in the
Department of Gynecology and Obstetrics of former Shanghai Municipal First People’s
Hospital. I had the honor to be admitted to this hospital for further education between 1964 and
1965 and was instructed by respectful Professor Lin. At that time, he was there to guide the
joint development of hysteroscope with the medical instrument factory and to observe an iso-
lated uterus. Professor Lin’s careful thinking, rigorous style of work, and relentless pursuit
impressed me deeply. Inspired by his spirit, I inherited my teacher’s unfulfilled wish. Since
1990, I have committed myself to the introduction, clinical application, and basic research of
hysteroscopy, and I have accumulated a large number of image data. Today, hysteroscopic
technique has already been mature. To popularize this procedure in our country and benefit the
broad masses of women, the Ministry of Health has listed hysteroscopic techniques as one of
10-year 100 projects of 2001. In view of fewer related works at present and lack of systematic
atlas monographs, well-known experts and scholars domestic and abroad were invited to edit
this book under the energetic support of Henan Science and Technology Press.
I dedicate this book to my first teacher in hysteroscopy Prof. Lin Yuanying and also to Prof.
Song Hongzhao, Prof. Zhou Suwen, Prof. Li Zixin, and Prof. Liu Zongtang, who supported and
encouraged me a lot. And my most sincere gratitude goes to Mr. Liu Xuegang, Mr. He Baijiang,
Mrs. Li Jihong, Mrs. Liu Ya’an, and Mrs. Zhang Meng from Japan’s Olympus Corp. Beijing
Office, who helped me in collecting images and providing equipment and technical support.
I sincerely welcome colleagues domestic and abroad to give me more valuable advice so as
to make it better in time if there are some careless omissions.
In April 2001, the tenth meeting of the International Society for Gynecologic Endoscopy
held in Chicago, USA, put forward a target to the gynecological workers of the whole world:
“To 2025, most of gynecological surgeries will be replaced by endoscopic operations.” This
will inspire and guide us to develop our hysteroscopic techniques and render unremitting
efforts to the implementation of international standards.
June 2002 Enlan Xia
ix
Preface
This is a delicate book with precious atlas and a fruit of hard work. As a monograph on medi-
cine, we’d rather attach much importance to great amounts of data obtained through long time
of practice, accumulation and summarization combined with scientific analyses and elabora-
tion in relation to academic viewpoints. In view of clinical medicine involving highly practical
technology, especially the laboratory techniques and operating techniques, their popularization
is of great significance. And clear elaboration, lucid expression, and justified statement on the
latter are extremely difficult to make.
However, after I read through the book An Atlas of Hysteroscopy, edited by Prof. Xia Enlan,
I felt shocked and greatly excited! The reason is that this is just the kind of professional works
on technology that we have expected. And its contributors are all experienced experts in hys-
teroscopy especially those from the hysteroscopic center under the leadership of Prof. Xia,
who are richly experienced and have achieved brilliant achievements. And more valuably, this
center has constantly recruited visiting physicians and postgraduates and has trained a large
number of professional and technical personnel throughout the year, so this is a well-deserved
training center and a cradle of specialists.
Hysteroscopy and laparoscopy, being a major tool and technical source of gynecological
endoscopy, have been widely extended in their diagnosis and treatment and have promising
prospects. If you’d like to make good use of them, first, you should know well about their
indications and contraindications, then, have a good command of their techniques and skills,
and you also should be always on guard against the occurrence of complications. Standardization
of techniques and training for operators are indispensable “double-track railway” in the prog-
ress of technology. Endoscope-related accessories, energy source, and limited space and vision
have posed new problems for surgery, so it seemingly becomes a “double-edged sword,” that
is, a minimally invasive surgery may be turned into a maximally invasive surgery. And through
reading this book you may grasp its gist and understand its meanings. So when such kind of
book is often called “cookbook,” I beg to differ. And what’s more, even though it is a cook-
book, the ingredients and procedures described, if managed by different hands, may have quite
different flavors! How important the cooking skill and cooking temperature control is! Let
alone the much more complex hysteroscopic technique. Illness differs from person to person,
so we can’t “look for a steed with the aid of its picture”; it depends on individual’s power of
understanding, intelligence, experience, and personal skill. Learning from others through read-
ing improves one’s own ability, in a sense, as the saying implies, “Laymen are overwhelmed
by the fun while professionals try to find out the trick” and “A master may teach, but progress
is up to the hard work of an individual.” We are running after a lot of new dreams (they are not
necessarily all splendid), but more importantly, we need calmness and reflection, including
summarization, analysis, and deduction from our daily work, just as the book contributed by
Prof. Xia together with other authors.
xi
xii Preface
Professor Xia is our respectable senior. Upon her order, I wrote these out of my own heart,
which aren’t be but a preface.
Beijing, China Jinghe Lang

Chinese Gynecological Endoscopy Group
Beijing, China
Chinese Academy of Medical Sciences
and Peking Union Medical College
Beijing, China
Obstetrics and Gynaecology in Peking Union
Medical College Hospital
Beijing, China
At Mid-Autumn of 2002
Abstract
The book is made up of 16 chapters, in which a systemic introduction is made to the history of
hysteroscopy, hysteroscopic equipment and instruments, applied anatomy and histology in
relation to hysteroscopy, distention media and perfusion system, anesthesia for hysteroscopy,
and so on. This book elaborates on the application of diagnostic hysteroscopy and operative
hysteroscopy in the treatment of gynecological diseases, combined hysteroscopy and laparos-
copy, and hysteroscopic surgery under ultrasound monitoring. This book also expounds inci-
sively on the technical training and the trend in the future development of hysteroscopy. At the
end of this book, a report sheet of hysteroscopic examination, routine orders in hysteroscopic
ward, patient consent form prior to hysteroscopic surgery, and operating manual for hystero-
scopic electroresection are attached so as to help readers to standardize the hysteroscopic
examination, diagnosis, and surgeries.
This book is based on rigorous and scientific research with emphasis on a combination of
theory and practice, in which various typical cases are redisplayed clearly by more than 700
color photos to facilitate readers’ understanding and grasp of hysteroscopy. Meanwhile, it is
also a professional and reference book for medical students, gynecologists, and nurses at all
levels to use.
Cataloguing in publication (CIP) data
An Atlas of Hysteroscopy/Edited by Xia EnLan—the third edition
An Atlas of Hysteroscopy/Editor-in-chief: Xia EnLan.—third edition.—Zheng Zhou:
Henan Science and Technology Press, 2015.4
ISBN 978-7-5349-3958-7
I. Hysteroscopy II. Xia EnLan III. Hysteroscopy—Atlas IV.R711.740.4–64
Chinese Version Library CIP Data Reg. No. 118839 (2008)
Published and issued by: Henan Science and Technology Press
Address: Jingwu Road No. 66, Zhengzhou City, China
Postcode: 450002
Tel: 0086-(0)371-65737028 65788627
URL: www.hnstp.cn
Editor in charge: Ma Yanru
Proofreader in charge: Ke Jiao
Cover designer: Zhang Wei
Layout designer: Sun Song
Printed by: Zhengzhou New Coast Computer Color Printing CO., Ltd
Distributed by: National Xinhua Book Stores
Page size: 185 mm × 260 mm
Printed sheet: 29.5 Number of words: 580,000
Edition: Third published in May 2015. First Printed in May 2015
xiii
Contents
1
History and Development of Hysteroscopy �� 1
Enlan Xia
2
Equipment and Instruments for Hysteroscopy �� 7
Xuegang Liu, Baoliang Lin, and Yan Quan
3
Anatomy and Histology in Hysteroscopy�� 29
Enlan Xia
4
Effects of Preoperative Medication for Hysteroscopy and Commonly
Used Drugs in Gynecology on Endometrium�� 31
Xiaowu Huang
5
Application of High Frequency Electricity in Hysteroscopic Surgery
and Its Thermal Effects on Tissues�� 41
Hua Duan
6
Distention Medium in Hysteroscopy�� 51
Limin Feng
7 Anesthesia for Hysteroscopy �� 65
Handong Cai
8 Diagnostic Hysteroscopy�� 73
Enlan Xia and Dan Yu
9 Operative Hysteroscopy�� 183
Enlan Xia, Ning Ma, Xuebing Peng, Dan Yu, and Jie Zheng
10
Combined Hysteroscopy and Laparoscopy �� 337
Enlan Xia
11
Ultrasonography Monitoring During Hysteroscopic Surgery �� 353
Dan Zhang
12
Complications of Hysteroscopic Surgery�� 365
Enlan Xia, Rafael F. Valle, Xiaowu Huang, Dan Yu, Yuhuan Liu,
and Baoliang Lin
13
Hysteroscopy for Other Purposes�� 421
Jie Zheng and Enlan Xia
14 Hysteroscopy Training�� 433
Enlan Xia and Xiaowu Huang
15
The Future of Hysteroscopy�� 435
Enlan Xia
xv
xvi Contents
16 Digital
Storage and Application of Endoscopic Image �� 437
Baijiang He
Appendix 1: Routine Orders in a Hysteroscopic Ward �� 441
Appendix 2: A Practical Manual of Hysteroscopic Surgery �� 449

Appendix 3: Patient Consent Form for Hysteroscopic Operation
in the Hysteroscopy Center of Fuxing Hospital, Capital Medical University �� 461

Appendix 4: Patient Consent Form for Hysteroscopic Diagnosis
in the Hysteroscopy Center of Fuxing Hospital, Capital Medical University �� 463
Appendix 5: Report of Diagnostic Hysteroscopy�� 465

Editor and Contributors
About the Editor
Enlan Xia, graduated from Northwestern Medical College in

1955, has been engaged in teaching and research on clinical obstet-
rics and gynecology for more than 50 years. Nowadays she is a
professor of Obstetrics and Gynecology in Capital Medical
University, supervisor of graduate students, head of the
Hysteroscopic Center of Fuxing Hospital, Capital Medical
University, director of Beijing International Hysteroscopic
Training Center, member of American Association of Gynecological
Laparoscopists (AAGL), a lifetime member of the International
Society for Gynecologic Endoscopy (ISGE), an editorial board
member of Chinese Journal of Obstetrics and Gynecology,
Chinese Journal of Practical Gynecology and Obstetrics, Journal
of Practical Obstetrics and Gynecology, and Foreign Medical
Science: Section of Obstetrics and Gynecology. She has won 22
governmental awards for scientific and technological progress at
all levels from the Ministry of Health, Beijing Municipal Science
and Technology Commission, Beijing Municipal Health Bureau,
and Xicheng District Government. In 1992, she started to enjoy
special government allowances of the State Council. Under her
drive, “hysteroscopic technology” was listed as 10-year 100 proj-
ects for popularization by State Ministry of Health in 2000 and the
key project in 2001 and 2003. The research project “Clinical appli-
cation and basic research of hysteroscopy” won the second prize of
2004 State Scientific and Technological Progress Award.
Professor Xia Enlan is the founder and pioneer of gynecologic
endoscopy—hysteroscopic diagnosis and therapeutics in China. In
1990, she took the lead in the introduction and implementation of
hysteroscopic electroresection in China. In 1993, the first domestic
hysteroscopic center was established to further clinical practice
and scientific research. Since then, 20,000 diagnostic hysterosco-
pies, more than 8000 procedures of hysteroscopic electroresection,
more than 3000 cases of laparoscopic surgeries, and 1000 cases of
hysteroscopy combined with laparoscopy have been performed
over more than 10 years. Professor Xia has extremely proficient
skills in hysteroscopic surgeries and has formed her unique style,
which is praised as “Xia’s style” by counterparts domestic and
abroad, and the success rate of hysteroscopic surgeries has been at
the international advanced stage. And many a time she has paid
visits to the United States, France, Germany, Japan, Holland,
Switzerland, and other countries and Hong Kong, Taiwan, and
xvii
xviii Editor and Contributors
other regions for communication and lecturing. She has held 12

Beijing International Academic Symposiums and 90 workshops in
different places of China and has trained more than 400 physicians
from our country and other countries like Australia, Philippines,
and others for advanced learning.
Professor Xia is notable for her noble medical ethics and medi-
cal skills. She has long been diligently committed to the popular-
ization of hysteroscopy and enhancing China’s international status
in the scientific community of obstetrics and gynecology so as to
relieve pains for many more patients.
Contributors
Handong Cai Department of Anesthesiology, Fuxing Hospital, Capital Medical University,

Beijing, China
Hua Duan Minimally Invasive Center, Beijing Obstetrics and Gynecology Hospital, Capital
Medical University, Beijing, China
Limin Feng Department of Obstetrics and Gynecology, Beijing Tiantan Hospital, Capital
Medical University, Beijing, China
Baijiang He Endoscope Marketing Department, Olympus (Beijing) Sales and Service Co.,
Ltd, Beijing, China
Xiaowu Huang Hysteroscopy Center, Fuxing Hospital, Capital Medical University, Beijing,
China
Baoliang Lin Department of Obstetrics and Gynecology, Kawasaki Municipal Hospital,
Kawasaki, Japan
Xuegang Liu Endoscope Marketing Department, Olympus (Beijing) Sales and Service Co.,
Ltd, Beijing, China
Yuhuan Liu Hysteroscopy Center, Fuxing Hospital, Capital Medical University, Beijing,
China
Ning Ma Hysteroscopy Center, Fuxing Hospital, Capital Medical University, Beijing, China
Xuebing Peng Hysteroscopy Center, Fuxing Hospital, Capital Medical University, Beijing,
China
Yan Quan Operating Room, Fuxing Hospital, Capital Medical University, Beijing, China
Rafael F. Valle Department of Obstetrics and Gynecology, Northwestern University Medical
School, Chicago, IL, USA
Enlan Xia Hysteroscopy Center, Fuxing Hospital, Capital Medical University, Beijing, China
Dan Yu Hysteroscopy Center, Fuxing Hospital, Capital Medical University, Beijing, China
Dan Zhang Department of Ultrasound, Fuxing Hospital, Capital Medical University, Beijing,
China
Jie Zheng Hysteroscopy Center, Fuxing Hospital, Capital Medical University, Beijing, China
Editor and Contributors xix
Translators
Tin Chiu Li Department of Obstetrics and Gynaecology, The Chinese University of Hong
Kong, Hong Kong, China
Dan Yu Hysteroscopy Center, Fuxing Hospital, Capital Medical University, Beijing, China
History and Development
of Hysteroscopy 1
Enlan Xia
The history of hysteroscopy could be traced back to 150 years Table 1.1 (continued)
ago. Under the influence of low productivity, the hystero- Year Inventor Contributions
scopic technique was developed very slowly. Until the twen- 1942– Norment Rubber balloon, practical irrigating
tieth century, it improved gradually, especially in recent 1970 system, cutting loop, fiberoptics
20 years, the evolution of operational hysteroscopy brought 1952 Forestier First cold quartz light source
epoch-making revolution in the treatment of some gyneco- 1953– Mohti and Fiber hysteroscope, falloposcope
1978 Mohri
logical diseases. The advances of hysteroscopic technique
1957 Englund etc. Evaluation of abnormal uterine
are owing to the contributions made by many innovators, bleeding with hysterography, curettage,
whose years of continuous efforts innovated the means of and hysteroscopy
diagnosis and treatment for today’s gynecologists and obste- 1962 Silander Research focused on endometrial
tricians. This chapter will describe several different histori- cancer
cal periods, especially the important stages in which the 1965 Hopskin Development of optical fiber system
1968 Menken Hysteroscopic tubal occlusion with
uterine cavity could be revealed in front of us (Table 1.1). polyvinyl pyrrolidone (PVP)
1970 Edstrom and 32% dextran as distending medium
Fernstrom
Table 1.1 Milestones in the development of hysteroscopy 1970 Quinones et al. Hysteroscopic tubal catheterization
1972 Lindemann Set a safe flow rate of CO2 in
Year Inventor Contributions distending uterine cavity and applied
1807 Bozzini First endoscope (sunlight source) cervical vacuum cup
1869 Pantaleoni First hysteroscopy on human body 1974 Edstrom Therapeutic hysteroscopy
1879 Nitze Cystoscope with distal source of light 1974 Parent et al. Contact hysteroscopy
1889 Clado First designer of hysteroscopic 1978 Sugimoto et al. Normal saline as distending medium
instruments 1978 Neuwirth Use of resectoscope
1907 David First contact hysteroscope 1980 Quinones- 5% glucose solution as distending
1914 Heineberg Uterine distention system Guerrero medium
1925 Rubin Uterine distention with carbon dioxide 1980 Hamou Microcolpo-hysteroscope
(CO2) 1981 Goldrath et al. Laser endometrial ablation
1926 Seymour Hysteroscope with separate inflow and 1981 Feng Zanchong First diagnostic and therapeutic
outflow channels et al. hysteroscopy in China
1927 Mikulicz- Functions of biopsy and intrauterine 1988 Lin Baoliang Roller-ball endometrial ablation
Radecki cornual electrocauterization 1989 Magos et al. Transcervical resection of endometrium
1928 Gauss Uterine distention with the help of the 1990 Xia Enlan et al. First hysteroscopic resection in China
height of fluid
1997 Glasser Hysteroscopic vaporizing electrode
1934 Schroeder Measurement of intrauterine pressure
1997 Bettocchi Vaginoscopy
1934– Segond Distention system and biopsy
1999 Vilos Use of coaxial bipolar electrode
1943
2005 Olympus Ltd Saline plasma bipolar resectoscope
1936 Shack Verification of its clinical application
2005 Emanuel and Intrauterine morcellator
Wamsteker
2009 Papalampros Mini-resectoscope
et al.
E. Xia (*)
Hysteroscopy Center, Fuxing Hospital, Capital Medical University,
Beijing, China
© Henan Science and Technology Press 2022 1

E. Xia (ed.), Practical Manual of Hysteroscopy, https://doi.org/10.1007/978-981-19-1332-7_1
2 E. Xia
1.1 The First Hysteroscope the uterine cavity impeded the application of hysteroscopy
and its popularization.
The key to invent hysteroscope is how to introduce the instru- In 1879, Nitze invented the cystoscope, which used an
ment into the uterine cavity and use the external light source incandescent lamp with platinum wire for illumination, and
to view the interior of the uterus. flowing water for cooling of the lamp. Because of the thin
Philip Bozzini (1773–1809) first invented an instrument, bladder wall and the avascular cavity, such kind of endo-
which could be used to see hollow organs inside the body. scope was very suitable for the bladder examination.
The light conductor he designed was to refract the external
light through a channel and this channel was separated into
two parts by a vertical concave mirror, by which the light was 1.2 Contact Hysteroscope and Modern
refracted into the uterine cavity. He developed different types Contact Hysteroscope
of such devices so as to adapt to the different hollow organs
of the human body, such as oral cavity, nasal cavity, external In 1907, David first invented a contact hysteroscope that per-
auditory meatus, vagina, cervix and uterus, ureter and blad- mitted a direct visualization of endometrial surface without
der, and rectum. Although Bozzini published a brief descrip- distention of the cavity. Because infection might be spread
tion of this instrument in Frankfurt’s newspaper in 1804, it through the distending medium, the contact hysteroscope
was not until 1805 that he declared the accomplishment of his had a great advantage in preventing infections. It was com-
design in German newspaper, which enabled people to visu- monly used in postmenopausal or post-abortion patients.
alize the interior cavities of human body. Only in 1807, a for- After that, many scholars improved the magnification of
mal and elaborate report about such devices was published. David’s contact hysteroscope, including Palmer (1942),
Bozzini had been in dispute with the bureaucrat and intel- Norment (1947), Marleschki (1966), Parent (1974),
lectuals over his inventions, but today he was recognized as the Hamou (1980), and so on. Although the contact hystero-
father of endoscope. On the wall of Frankfurt Cathedral, scope has been getting simple, it still could not assess the
Bozzini’s epitaph was written in Latin: “To the devote soul of whole uterine cavity accurately and comprehensively.
Philip Bozzini, doctor of medicine, who was the first to explore Therefore, it is only suitable for inspections of cervical
the inside of organs through his ingenious light projector. He mucosa or the areas suspected of pathological lesions
was able to tenaciously fight fever in other people, with a great under panoramic hysteroscopy, and observation of endo-
sense of duty, and succumbed on the night from the 4th to the 5th metrial blood vessels.
day of April 1809, in his 36th year of life. His faithful friend F.F.” In the middle of the twentieth century, when doctors were
In 1853, a French urologist, Antonin J. Desormeau, first at a loss which was the best, Parent and his colleagues (1974)
introduced a truly workable cystoscope to the French reported an improved technique. It was a modified instru-
Academy of Medicine. With this, he could observe through a ment of David and Marleschki’s contact hysteroscope by
central channel. The light source was a turpentine oil lamp enclosing a glass rod in a metal sheath, which could reflect
which was refracted into this channel through a mirror. When the external light for the illumination of the uterine cavity. In
the light got to the halfway of it, it could be refracted through order to meet the requirements of examinations, the instru-
a concave mirror to any cavity observed. This device permit- ment was made of different sizes, of which the outer sheath
ted the observation of a full bladder through a lens at the was 4 mm, 6 mm, or 8 mm, respectively. This technique
distal end of the endoscope, and other operative instruments seemed to be simple and immediate, but could not make a
could be introduced through the side channel. 12 years later, comprehensive and accurate assessment of the uterine cavity.
Cruise, from Dublin, improved Desormeaux’s endoscope. Furthermore, direct biopsy was impossible with it and could
He applied a petroleum lamp with a mixture of a bit of dis- only be used in diagnosis.
solved camphor instead of turpentine oil lamp, and added a The emerge of panoramic hysteroscope dwarfed the con-
glass chimney to hold the vapor. In 1869, Pantaleoni, who tact hysteroscope. In 1983, Hamou made some improve-
had learned how to manipulate the endoscope from Cruise, ments on the contact hysteroscope, called
underwent hysteroscopy for a patient with postmenopausal vaginal-hysteroscope. Such hysteroscope could be a contact
abnormal uterine bleeding. Polypoid tissues were detected at type or a panoramic one, and its magnification ranged from 1
the fundus of the uterine cavity, and were cauterized with to 150 times. When doing panoramic hysteroscopy, if endo-
silver nitrate under the hysteroscopic guidance. metrium was found suspicious, it could be switched to a con-
After Pantaleoni performed the first hysteroscopic exami- tact type to magnify the tissue by 80–150 times to be
nation and treatment, many doctors began to utilize this new inspected. At present, such kind of method is used to observe
technique. However, poor light conduction, impaired vision the endometrial blood vessels, especially of the cancerized
owing to intrauterine bleeding, and inadequate distention of area, but not as a routine examination.
1 History and Development of Hysteroscopy 3
1.3 Hysteroscope with a Balloon In 1936, Shack sought to clarify the hysteroscopic indica-
at the End tions, and he attributed the failure of hysteroscopy to poor
view. Almost at the same time, Segond used fluid as disten-
Based on Norment’s design, the redesigned hysteroscope tion medium in France in 1934. They readjusted fluid inflow
had a transparent balloon attached to the distal end, which channel and outflow channel so as to obtain optimal uterine
was of plastic or silicone rubber instead of a rubber bal- distending effects and reduce the fluid into the peritoneal
loon, and it was thinner, more transparent, and more diffi- cavity. The object lens of telescope obliqued forward, which
cult to rupture. Wulfsohn (1958) and Bank (1960) made it easy to view the uterine cornua and tubal ostia, but
conducted the first evaluation of this hysteroscope. intrauterine bleeding remained a major obstacle to observe
Although it had a clear vision and avoided the distention the uterine cavity.
medium infiltrating into the peritoneal cavity, the com- American scholar Norment developed an air bag being
pression of balloon on the endometrium distorted and introduced into the uterine cavity when conducting intra-
twisted the endometrial tissues. In addition, biopsy and uterine observations, which avoided the infiltration of fluid
resection remained inaccessible. Thus people soon real- into the peritoneal cavity, and obtained the expansion of
ized its limitations and then forbidden its use. Soon mod- uterine cavity without distention medium. The low-viscos-
ern hysteroscope turned to the use of distention medium to ity continuous fluid infusion system that Norment designed
distend the uterine cavity. was the model of modern continuous flow hysteroscope and
resectoscope. In 1957, Norment designed an electric resec-
toscope which used a cutting loop to remove the submucous
1.4 Fluid Irrigation Mode (Original myomas and polyps. Eighteen years later, he finalized the
Continuous Irrigation System) design.
and Uterine Distending Medium Friedrich-Carl Menken (1968) firstly used high-viscosity
uterine distention medium—polyvinyl pyrrolidone (PVP).
Like cystoscope, to observe uterine cavity required disten- Compared with the low-viscosity distention medium, it
tion medium to distend the cavity. Heineberg in 1914 and rarely infiltrated into the abdominal cavity. However, because
Seymour in 1926 developed the hysteroscope with inte- PVP could not be degraded, and the liquid was light yellow
grated fluid inflow and outflow channels, which founded after dissolution, it was not widely applied.
the basis for later continuous flow hysteroscope. Inspired In 1970, Edstrom and Fernstrom used dextran with 70,000
by bronchoscope, in 1926, Seymour modified the hystero- molecular weight (MW) to distend the uterine cavity. The
scope to diagnostic type and operative type, and the latter reduced volume of its usage could greatly reduce infiltration
can be used for the resection of submucous myomas and of the liquid into the peritoneal cavity and high-viscosity
other intrauterine lesions. He had conducted a 6-mm- dextran could not mix with blood, so it might not interfere
diameter bronchoscope with its distal end connected to a with the view because of bleeding, and could keep the uter-
suction device, and continuous suction helped to observe ine cavity with a certain pressure as well.
the uterine cavity. A 9-mm endoscope had been applied, When the researchers engaged in the research on tubal
through which a biopsy forceps could be used to remove ostia sterilization by diathermy (1972), Quinones-Guerrero
the intrauterine tissues. Later Seymour adjusted the diam- and his colleagues began to perform operative hysteroscopy
eter of endoscopic sheath to 6 mm, which appeared to be using low-viscosity distending medium. They adopted
very practical, but there are no more clinical reports to Norment’s design to pumping liquid into the uterine cavity
confirm it. with the tourniquet or pressurized pump. Sugimoto (1978)
In 1928, Gauss reported that a diagnostic hysteroscopy used low-viscosity liquid like saline, connected the syringe
was performed using low-viscosity fluid and gained a clear to the joints, and increased the pressure according to the
image of uterine cavity. On this basis, Schroede tested out requirements of the uterine cavity. However, the problem of
the most suitable pressure so as to get the best view and excessive fluid absorption through blood vessels still
avoid the leakage of distention fluid from fallopian tube. He remained to be solved.
found that the container with distention fluid could be placed
at the different heights along with the change of the intrauter-
ine pressure. The most suitable pressure was 25–30 mmHg, 1.5 Distention of Uterus with CO2
and when the pressure exceeded 55 mmHg, the fluid would
flow into the abdominal cavity via fallopian tubes. In addi- In 1925, Rubin attempted CO2 to distend the uterine cavity,
tion, he applied hysteroscopic coagulation for tubal which made him the father of tubal insufflations with CO2.
sterilization. Nevertheless, most doctors would still like to apply low-
4 E. Xia
viscosity distention fluid. In 1927, Mikulicz-Radecki 1.8 A Clinical Review

reported the hysteroscopic diagnosis and treatment with fluid
distention. These procedures included biopsy, resection of In addition to Norment, Mohri, and Palmer, many other
lesions in the cavity, and diathermy of tubal interstitial for researchers had been indulged in the development of equip-
contraception, etc. ment and techniques, but few of them focused on how to use
In 1971, Lindemann reported the use of CO2 in expanding these techniques. Englund et al. published a valuable article
the cavity. A normal flow rate of CO2 in distending uterine about patients who had abnormal uterine bleeding and under-
cavity was 40–100 mL/min, with the pressure <200 mmHg. went hysteroscopy followed by curettage. In total, 165
CO2 is clean and capable of gaining a clear view, and it may women had diagnostic curettages during hysteroscopy, of
help to provide high definition pictures of the uterine cavity. which 21 cases had hysterography beforehand. Among 109
Hence Lindemann thought it was the best distension medium. women who had hysteroscopy and curettage, the accuracy of
With the improvement of the equipment, and the automatic hysteroscopic diagnosis was 93%. They found hysteroscopy
control of gas flow rate and pressure, the fatal complications was superior to hysterography in diagnosis. Among 124
due to excessive gas injection and higher pressure were women who had diagnostic curettage, only 44 cases (35%)
avoided. were confirmed by operation, and most pathologies includ-
ing abnormal tissue, polyps, and submucous myomas were
missed by hysterography. Over 5 of 46 cases who had second
1.6 Invention of Fiber Hysteroscope hysteroscopy were found to have disagreement with the
operational results.
In 1954, Basil I. Hirschowitz first invented optical fiber.
Later, he applied it to flexible hysteroscope. Fiberoptic endo-
scope was also applied to the hysteroscope with a plastic air- 1.9 Other Innovations
bag at the end, which permitted the examination of embryo
and fetus outside the amniotic membrane without distention In 1976, Neuwirth applied prostatic resectoscope to remove
medium (1968). In 1975, Mohri first used flexible hystero- submucous myomas, whereas continuous irrigation was not
scope with the optical fiber to observe early pregnancy used in the original resectoscope, so myoma fragments could
embryos. When using the miniaturized fiber endoscope to not be cleared promptly. Later, Iglesias and his colleagues
observe fallopian tube, falloposcope was born. In 1973, changed the sheath of resectoscope to be round, and utilized
M. Hayashi also evolved a similar mini fiber endoscope for the continuous flow system, therefore the operation view was
the observation of fallopian tube and successfully visualized clean and clear. These evolutions created a new field for elec-
the fallopian tube lumen. tric surgeries in uterine cavities.
In 1981, Goldrath performed Nd-YAG laser endometrial
ablation on patients who had abnormal uterine bleeding
1.7 Continuous Flow Hysteroscope and did not respond to drug therapy. This therapy, which
was approved by FDA in 1986, seemed to be very effective,
A lot of medical apparatus and instruments companies especially for those who had hysterectomy contraindica-
attempted to design continuous flow systems with many dif- tions. But soon, laser was replaced by electric surgery. In
ferent plans to make the low-viscosity fluid distention sim- 1989, FDA formally approved the use of electric
pler. Continuous flow system could also be applied to resectoscope.
hysteroscope with 4–6 mm outer sheath. In addition, with the The emergence of new techniques at the end of the 1980s
developments of instruments and maintenance, hystero- also made successive improvements on equipment. The most
scopic diagnosis and operation were moved from the opera- important breakthroughs were:
tion room and hospital to outpatient department. With the
improvement of telescope, 2–3 mm mini hysteroscopy can 1. Both operative and diagnostic hysteroscopy adopted con-
also be used without continuous flow system. tinuous flow system, which could effectively control the
Hysteroscope with continuous flow started to replace the flow rate and intrauterine pressure;
one-way irrigating hysteroscope, by which the flow rate and 2. Imaging technique was also developed rapidly. Most
intrauterine pressure could be controlled. These improve- problems baffled doctors were solved in the early 1980s.
ments led to the development of accessorial instruments, The invention of couple charge device (CCD) solved the
such as monopolar electrode and bipolar electrode. problem of miniaturizing the video camera, which could
Vaporization electrode can make the tissue fragments vapor- be connected with the eyepiece and transmit the image on
ized. In addition, bipolar electrode allows for ionic liquid to the TV screen. It could greatly improve the definition of
distend uterine cavity, thus avoiding hyponatremia caused by images, relieve the fatigue of operator’s neck and back
the liquid absorption. when observing and operating through the eyepiece, and
1 History and Development of Hysteroscopy 5
reduce the doctors’ labor intensity. Television monitoring from many times of insertion and withdrawal of hys-
system could also record and playback the procedure of teroscope for taking out intrauterine myoma fragments,
operation, which might be used in analysis and review and significantly decreased the risk of some severe com-
after operation. The fluid infusion pump which was spe- plications including excessive fluid deficit, hyponatre-
cially designed for hysteroscopic resection could set the mia, and uterine perforation. In 2009, an improved
pressure and flow rate, so that the operation could be done instrument named “MyoSure” was developed for
under satisfactory distension of uterus and clear vision. removal of intrauterine tissues. It was more convenient
Its fluid outflow collection device could provide the fluid for outpatient operation because of its small diameter
deficit by accurately calculating the amount in inflow and and fast cutting speed.
outflow containers, thus preventing TURP syndromes 6. The development of Mini-resectoscope. In 2009,
effectively. Papalampros et al. reported the application of a 5.3 mm
3. A vaginoscopic approach was adopted for hysteroscopy. diameter monopolar resectoscope, which was used to
In 1997, Bettocchi first reported the use of vaginoscopic remove endometrial polyps and small type 0 or 1 sub-
hysteroscopy. It was introduced into vagina without spec- mucous myomas, and achieved a satisfying treatment
ulum. Under the help of vaginal expansion with normal result.
saline irrigation, it could clearly visualize both the vagi-
nal wall and cervix. Then it progressed into uterine cavity When looking back on 180 years of hysteroscopy, many
through cervical canal. All the abnormalities from vagina, of the early problems, such as poor view of operation, inap-
cervical canal, and intrauterine cavity could be detected propriate distending medium, inadequate expansion of uter-
and managed. This technique avoided the introduction of ine cavity, the larger diameter of endoscope, have been
speculum, dilation of cervical canal, and measurement of gradually settled. This technique has evolved for a long time,
endometrial cavity length, and therefore preserved the so today we can smoothly perform operations inside the uter-
integrity of hymen in young girls and virgins. In recent ine cavity. When recalling the history of hysteroscopy, we
years, it has become a commonly used diagnostic and paid great and deep respects to all the pioneers. It was their
operational technique for young girls, virgins, and older innovations together that brought us such a safe, simple, and
women due to its reduction of injury and discomfort effective hysteroscopic technique.
caused by speculum.
4. The utilization of bipolar resectoscope. In 2005, Olympus
Corporation in Japan produced a plasma bipolar resecto-
scope. It used saline as distention medium so that it Suggested Reading
greatly reduced the occurrence of TURP syndrome, it
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1997;4:255–8.
quency current could convert saline to electric plasma
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Equipment and Instruments
for Hysteroscopy 2
Xuegang Liu, Baoliang Lin, and Yan Quan
Since Pantaleoni applied the first hysteroscopy in 1869, with 2.1 Equipment for Hysteroscopy
the help of candlelight and concave mirror on human living
body and found cervical polyps in a woman with postmeno- Xuegang Liu
pausal vaginal bleeding, quite a few scholars have committed
to exploring the mystery of uterine cavity in the next
100 years. But due to the physiological and anatomical char- 2.1.1 Power System
acteristics of uterus and the limitation of instruments and
optical-electrical system, optimal results were hardly Power system is also called the energy system. The most
achieved. Until 1970s, with the emergence of fiber-optic commonly used energy sources for hysteroscopy are high
devices, cold light sources, and modified uterine-distending frequency electricity and laser. Compared with mechanical
method, the research and application of hysteroscopy operative hysteroscopy, their applications have broadened
regained attention and underwent rapid development. the type and extent of surgery inside the uterine cavity.
In the early 1990s, a new hysteroscopy video system was
applied in clinical practice. Modern hysteroscopic system 2.1.1.1 High-Frequency Current Generator
basically consists of several parts: hysteroscope and its A high-frequency current generator can generate current for
instruments (including diagnostic and therapeutic hystero- cutting tissues and (or) electro-coagulating vessels.
scope, and hystero-resectoscope), lighting system, disten- Generally, low frequency current may cause muscle and
tion/irrigation system, camera imaging system, and power nerve stimulation, while high frequency current does not,
system (high frequency electrosurgery, laser, etc.). Just as “A and cannot induce ventricular fibrillation, but may cause tis-
craftsman must sharpen his tools if he is to do his work well,” sue to heat up, carbonize, and be vaporized, resulting in
a handy telescope and instruments, a bright and clear imag- coagulation and incision. The current frequency usually
ing system, good uterine distension, and a safe and conve- reaches hundreds of kilohertz. When the current passes
nient power system are premises and foundations to smoothly intensively through the tissue, it produces Joule heating,
carry out hysteroscopic diagnosis and treatment. which may make water evaporate from cells. As the water
evaporates, the tissue impedance increases further, and more
heat is produced. Thus it causes tissue protein to be denatur-
ized and dried, and then coagulated. As the temperature ele-
vates further, the tissue begins charring, and then arc
discharge is generated and vaporizes the tissue, which
achieves the effect of incision. Hysteroscopic operation is
conducted in liquid with relatively high impedance, thus it is
X. Liu (*) necessary to be equipped with a large power electric genera-
Endoscope Marketing Department, Olympus (Beijing) Sales and tor which has a power display and return power monitoring
Service Co., Ltd, Beijing, China system. Modern power generators are all equipped with an
B. Lin alarm system, hence it is safe and reliable when in use.
Department of Obstetrics and Gynecology, Kawasaki Municipal However, the connecting parts of high-frequency current
Hospital, Kawasaki, Japan
generator should be carefully checked before operation to
Y. Quan make sure not to burn the patients, for example, whether the
Operating Room, Fuxing Hospital, Capital Medical University,
electrode plate is placed appropriately or not, and whether
Beijing, China

8 X. Liu et al.
Fig. 2.1 SurgMaster

Electrosurgical Unit
(UES-40)
there is loose contact or wire falling off. Multifunctional When the fiberoptic laser is used for other intrauterine
high-frequency electrosurgical device may depend on surgery except for endometrial ablation, “bare” fibers must
changes in tissue impedance and be controlled by computer be avoided to reduce the depth of coagulation. New sculp-
to adjust output automatically instead of manually. This tured or extruded fibers, which can concentrate and focus the
technique ensures that electric knife can maintain the same laser to prevent scattering, have been introduced that permit
cutting and coagulating effects no matter what tissues are. dissection or cutting with little coagulation. Such laser fibers
This device also has the digitalized power output display, the can be used to divide intrauterine adhesions or a intrauterine
power-on self-test system, the automatic standby system, the septum, or for removal of a pedunculated submucous myoma.
poor circuit alarm, the overload output alarm, and the over- There is another kind of optical fiber, of which the sapphire
time output alarm. The power output stops automatically tip is attached to the quartz fiber of the Nd:YAG. This special
when it alarms, which ensures the safety of surgery. Because sapphire tip need to be cooled in liquid or gas medium during
its energy attenuation in liquid is faster than that in air, so the procedure. In contrast, it is safer to use liquid distending
high-frequency electrosurgical device is specially provided medium than a gas medium when doing laser operative hys-
with the tissue cutting mode in liquid (panel display URO), teroscopy, but the liquid medium used must have very strong
which ensures that it can do as fast and effective cutting in cooling capacity. Safety is relative, and improper use will
liquid as in air. UES-40 multi-functional high-frequency lead to excess absorption of distention medium. Improper
electrosurgical device (Fig. 2.1) covers almost every need of use of the gaseous coolants, including CO2, may also lead to
electrosurgery. It is applicable in conventional monopolar air embolism. In short, the fiberoptic laser with sapphire tips
resectoscope as well as bipolar and monopolar instruments, must do with the high velocity of liquid or gas exchange so
and also allows the procedure of cutting in saline. as to cool its tips. The velocity of thermal exchange medium
requires about 1 L/min. A non-refrigerant gas or cooling
2.1.1.2 Nd-YAG Laser through air is never allowed to use inside the uterine cavity.
The laser used for intrauterine surgery has been the
neodymium:yttrium aluminum garnet (Nd:YAG) laser,
which has the property of being attracted by the purplish- 2.1.2 Lighting System
colored tissue. The coagulating effect produced when in con-
tact with the tissue will lead to protein denaturalization and Because the outer diameter of the telescope used in intrauterine
deactivation of its front and lateral tissues, which is ideal to operation is very small, only an extremely strong light can
destroying the endometrium. Therefore it was most suitable make the vision clear. So far, the light guided through the light
for endometrial ablation. However, this laser is an invisible cable has high brightness and low heat dissipation, with a piece
light and located in the infra-red portion of the spectrum, of insulating glass located between light bulb and optical fibers,
with the wavelength 1064 nm, so it requires a guide of He-Ne therefore, it is traditionally called “cold” light source. The com-
light to reach the treatment area. When compared with CO2 monly used cold light-source bulbs are halogen lamps, metal
laser, it has more power, stronger penetrating, and more halide lamps and xenon lamps. These light sources with high
destructive effects on tissues. Fiberoptic lasers may deliver color temperatures may produce high brightness, natural col-
the laser energy through the operation channel of the hys- ors, and clear images. Xenon light with a higher color tempera-
teroscope. After being processed into the uterine cavity, it is ture is close to natural daylight and its bulb can be used for a
conducted in fluid medium and act on lesions without attenu- long time, therefore it is more suitable for endoscopic lighting,
ation of energy. and an ideal light source for hysteroscope.
2 Equipment and Instruments for Hysteroscopy 9
2.1.2.1 Cold Light Source

1. Xenon cold light source (Fig. 2.2): The high power 300 W
Xenon light source is equipped with both manual and
automatic brightness adjusting modes to maintain best
lighting, and higher brightness mode to increase the
amount of light by nearly 2 times. At the same time, a
150 W emergency Halogen lamp is equipped so as to be
switched on automatically to complete the necessary pro-
cedures when the main light is going off. The brightness
can be automatically adjusted when the light source is
connected to video systems via a light control cable. A
standby illumination can be set through the use of a
switch on the front panel or a remote control switch on
the camera heads. With intensity-mode memory, when
the light source is turned off no matter in what intensity
mode, it will still be in that mode when turned back on. It
can be also used in a variety of other flexible or rigid
endoscopes in addition to hysteroscope. There is a record
form for the use of light bulbs, and a waterproof panel
with concise and cozy design, which is easy to clean. The Fig. 2.4 CLH-250 light source
brightness of light sources is quantized display.
2. Metal halide light source (Fig. 2.3): This high power metal
halide lamp has high brightness with color temperature
close to natural light, and a long lamp life with smooth
consumption curve. The Olympus CLD-S is a multifunc-
tional light source with its brightness adjusted automati-
Fig. 2.5 Light guide bundle

Fig. 2.2 CLV-S40 light source
cally or manually. It also has an emergency lamp (150 W

halogen lamp) which ensures the safety of surgeries.
3. Halogen light source (Fig. 2.4): This high power 250 W
halogen lamp has high brightness and good color tem-
perature. It is convenient and intuitive in brightness
adjustment, and also has an emergency bulb (250 W).
2.1.2.2 Light Guide Bundle

Light guide bundle (Fig. 2.5) is also known as light cable,
consisting of a bundle of optical fibers with both ends to be
curved. It is a part of camera imaging system, which has high
quality to transmit light and connects the endoscope with
Fig. 2.3 CLD-S light source light source. When the light passes from one medium into
10 X. Liu et al.
another, the reflection and refraction can be seen at the can be preset and stored; automatic monitoring of fluid defi-
boundary surface. If the incident light cannot pass into the cit and alarming when exceeding the preset values ensure its
second medium, but is totally reflected back into the original safety. All these are very important in endometrial resection.
medium, this phenomenon is called the total reflection. Light Generally, fluid distending pressure is set at 80–100 mmHg
guide bundle is made up of the optical fibers with character- and the flow rate at 200–400 mL/min.
istics of total reflection.
In order to achieve the aims of total reflection of fiber
bundles, flint is used as the core fiber of glass fibers, coated 2.1.4 Camera Imaging System
with crown glass on the outer layer, called coating layer,
which solves the problem of insulation. Because refraction 2.1.4.1 Imaging System
rate of flint glass is higher than that of the crown glass, the Imaging system is to take the endoscopic images by camera,
irradiation of light on the inner surface of flint glass is analyze and process images by image processor, and then dis-
reflected to the opposite side of inner surface. Crown glass play them on the monitor, which includes CCD (charge cou-
acts as a coating layer, which solves the problem of the so- pled device) camera, video recorder, and monitor, etc. The
called insulation and prevents the light from leaking. After camera image sensor can turn a real image into an digital
repeated total reflection, the light shoots out from the other image, and display it on the screen. Nowadays, CCD image
end of the fiber. The diameter of each optical fiber is sensor is used in all cameras. However, it cannot recognize
10–25 μm, and each of the cables contains over one million color signals. Therefore, in order to obtain the color images, the
optical fibers. It is possible that optic fibers may break, and if presence of color must be realized through the prism or color
damaged, it can be found when optical cable is checked in filter. In China, hysteroscopic camera is of PAL signal system.
the daytime. The damaged fiber appears to be a black point. Most of video cameras in use now have VIDEO, Y/C, and
In order to extend the life of optical fibers, suggestions are as RGB output, and the high quality cameras have SDI or
follows: HDMI output.
Camera sensitivity, also known as the minimum illumina-
1. handle with care; tion, is the sensitivity degree of CCD to ambient light, or the
2. avoid the cable being folded into an acute angle; darkest light that CCD normal imaging requires. The unit of
3. after operation, the cable should be properly removed illuminance is lux (Lx). The smaller the values are, the less
from the endoscope and allowed to cool down before light needed, and the more sensitive the camera is. Lx 2 to 3
being replaced from the light unit. belongs to general illuminance, and now the minimum illu-
mination of medical endoscopic camera can reach 1.4 Lx.
Lux value is in inverse proportion to camera’s sensitivity.
2.1.3 Uterine Distention/Irrigation System Therefore, 10 Lx camera is clearer than 15 Lx camera, of
which the lower the Lux value is, the lower the light required
Hysteroscopic fluid pump is an automatic and accurate pres- for a satisfactory image.
sure controlled device, and makes up “UTEROMAT fluid The sharpness of video camera is expressed by the pixel
control system” together with its accessories (Fig. 2.6). More value, which decides the accuracy of the sensor, and is deter-
values like intrauterine pressure, flow rate, and liquid level mined by the number of the points forming the images. The
larger the pixel value is, the better the clarity of the image.
Therefore, low resolution video cameras of the earliest
150,000 pixel were replaced by high resolution cameras in
later years. This high-resolution video camera normally has
CCD sensor of 400,000–470,000 pixels.
The sharpness of video camera is defined by the number
of horizontal scanning lines of camera. The greater the
numerical value is, the higher the sharpness. The image of
video camera with existing CCD sensor can achieve 1080
lines and above.
The television image generated by video camera contains
the so-called noise. The noise appears in the form of fine
particles in the image, particularly in the dark or red zone.
The noise volume of video camera can be measured by the
signal/noise ratio (S/N), expressed in decibels (dB). The
Fig. 2.6 UTEROMAT fluid control system higher the ratio is, the smaller the noise of the image.
Some video cameras are equipped with imaging system tor must be at least equal to the number of the lines of the
under dim light. This system works through adding auto video camera, and it will be better if the monitor resolution is
gains, thereby improving the brightness of image. However, greater than that of video camera system. The size and reso-
it is much better if there is a strong light source than the lution of the monitor are two different concepts, so the
video cameras with auto gains function. requirement on the size of monitor is very subjective and 34
Finally, the video camera is generally equipped with auto- to 49 cm (14–20 in.) monitor could be chosen to one’s per-
matic shutter so that the video camera can adjust the shutter sonal preference. Generally, a monitor with 44 cm (18 in.)
speed to adapt to the light conditions. The shutter speed is screen diagonal is suitable for performing high quality
usually regulated between 1/30 and 1/10,000 s, thus allowing operations.
video cameras to be used in all light conditions. If such a The video camera is like the surgeon’s eyes, therefore, the
video camera is used, it is not necessary to apply an adjust- best video camera should be provided.
able light source.
The focal length of most video camera lenses is between 2.1.4.3 High Definition Digital Camera System
20 and 40 mm. Usually the lens has 110° optical angle, High definition digital camera system (Fig. 2.7) is a new-
35 mm focal length, and allows for full screen images. Some type digital camera system, which has high signal-to-noise
cameras have a focusing function, which can magnify the ratio, high image resolution (1080 p), and true color repro-
image. Therefore, even a minor diameter lens or a narrow duction. There are vertical and curved types of standard
angle lens may also obtain full screen images. If it is a video camera (Fig. 2.8a, b), respectively, for hysteroscopy
35 mm lens, full screen images usually can be achieved. The and laparoscopy. Different adapters (Fig. 2.9a, b) may be
use of light focusing means high consumption of light. chosen and applied in different endoscopes. In order to meet
Therefore, if the camera has focusing function, stronger the sterilization requirements of modern minimally invasive
light source will be required. Operative hysteroscopy is surgery, the cameras (Fig. 2.10) which can be sterilized
implemented through video monitor, and high resolution under high temperature and high pressure are developed. The
video camera can display the images of uterine cavity on the high resolution video camera with 470,000 pixels ensures a
monitor, through which assistants and other staff at the clear and natural image, and has the doubled sensitivity func-
operating room can understand the progress of operations tion and a new additional automatic metering function,
and cooperate with surgeons. It is also convenient for doc- which may ensure the brightness of the images in various
tors to explore and summarize the operational skills. The conditions. It also has a display function of wide depth of
new hysteroscopic imaging system makes the vision more field, making both distance and near vision clear and bright.
extensive, the image clearer, and observation and identifica- Two kinds of light adjusting modes - electronic shutter dim-
tion of lesions more detailed. Meanwhile, operators do not mer and dimming cable dimmer - ensure the best brightness
need to look through tiny telescope to observe uterine cav- of the images. Three-degree contour enhancement and white
ity, thus relieving the fatigue of operator’s neck and back balance functions help to adjust the color match according to
when operating, and obviously reducing the doctors’ labor the user’s preference. It has extremely strong adaptability to
intensity. different light sources, and the corresponding parameters can
The advanced modern 3CCD system makes its resolution be set according to the chosen light source. The waterproof
greater than 1080 lines, thus ensures a perfect image quality. panel simply and clearly designed is easy to operate and con-
Each CCD will only take in one color of RGB according to
its features. These three signals are processed in the camera
individually to ensure the balance and reality of color repro-
duction, just as the eyes see. The first focusing free video
camera in the world has a permanent and clear vision, and is
freed of trouble in adjusting the focus. 10 Lx digital proces-
sor makes the signal-to-noise ratio greater than 62 dB and
the clear images greatly relieve our visual fatigue. The first
CF electric protection video camera can reduce electric
leakage.
2.1.4.2 Monitor
The monitor is an important part of the monitoring system,
and should be selected according to the resolution of video
camera system, but the key is to indicate the quality of video
camera. The number of horizontal scanning line of the moni- Fig. 2.7 OTV—S7 digital camera system
12 X. Liu et al.
a b
Fig. 2.8 Standard camera head. (a) Vertical. (b) Curved
a b
Fig. 2.9 Adapter. (a) 0.8 magnification. (b) 1.2 magnification
venient for cleaning. The video camera head is waterproof so

it can be immersed and fumigated for sterilization. It has pro-
fessional red, green, and blue (RGB) output, and also the
Y/C (S- video) and component video output. Its integrated
digital image capturing system (Fig. 2.11) can do digital
recording. In addition to the standard camera, a lightweight
camera head with only 45 g is developed for being connected
to the telescope.
2.1.4.4 Other Application Systems

With the development of technology, various application
systems have emerged, such as voice-activated video camera
system (Fig. 2.12) and an integrated modern minimally inva-
sive operating room (Fig. 2.13) with a variety of
instruments.
Fig. 2.10 Autoclavable camera head
2.2 Instruments for Hysteroscopic

Diagnosis and Treatment
Baoliang Lin
There are two types of hysteroscope according to different

features—fiber hysteroscope (flexible hysteroscope) and
rigid hysteroscope.
2.2.1 Fiber Hysteroscope
The fiber hysteroscope is flexible, and both the image and light
are conducted by glass fiber bundles, so when the image is
enlarged, it appears to be meshy. This is its weakness when
Fig. 2.11 Digital image capturing system compared with rigid hysteroscope. However, when using glass
fiber, the hysteroscope can be finely-made with both sides of its
tip fixed with steel wire and the direction of its tips adjusted and
controlled by the manipulators at its handle. Anatomically,
uterus appears to be in positions of anteflexion or retroflexion.
Thus fiber hysteroscope is easier to be inserted into uterine cav-
ity than rigid hysteroscope, and easier to view both tubal ostia.
This is the advantage of fiber hysteroscope over rigid hystero-
scope. The comparison between them is given in Table 2.1.
According to the functions, fiber hysteroscope can be
divided into the following two types:
2.2.1.1 Diagnostic Fiber Hysteroscope (Fig. 2.14)

1. Total flexible fiber hysteroscope: The diameter of inser-
tion tube is 3.1 mm. In early stage, the examination of
uterine cavity was done by tracheal fiberscope or urethral
fiberscope instead of fiber hysteroscope. Because the
fiberscope was soft, it was often a problem to be inserted
Fig. 2.12 Host machine of voice-activated camera system into the uterine cavity. Therefore, a modified fiberscope
was developed by increasing its rigidity to facilitate the
insertion. Another characteristic is maintaining a clear
Table 2.1 Comparison between rigid hysteroscope and fiber

hysteroscope
Index Rigid hysteroscope Fiber hysteroscope
Image Bright Poorer
Magnification of the Yes (through camera Yes (through
image head) camera head)
Procedure Simple Slightly difficult
Insertion into the Sometimes difficult Easy
uterine cavity
Reaching the target Possible Slightly difficult
directly
Observation of tubal Sometimes difficult Easy
ostia
Duration of procedure Long Short
Price Less expensive More expensive
Fig. 2.13 Modern minimally invasive operating room Uterine perforation Possible Rare
Operator’s posture Uncomfortable Comfortable
14 X. Liu et al.
Fig. 2.14 Diagnostic fiber hysteroscope Fig. 2.15 New diagnostic fiber hysteroscope
vision when fixed with Lin’s outer sheath for continuous-

flow system.
2. Soft and rigid diagnostic fiber hysteroscope: The front
section of telescope is soft and flexible, the middle rigid,
and the rear flexible. Because the middle section is rigid,
it is easier to perform procedures in uterine cavity or
insert the telescope directly into the uterine cavity than
the total flexible fiber hysteroscope.
3. Diagnostic fiber hysteroscope without light guide bundle:
It is one of the total flexible fiber hysteroscopes, whose
Fig. 2.16 Continuous flow outer sheath
characteristic is the light source integrated with the hys-
teroscope. It is installed in itself with small bulb light
source and a dry cell battery for 1H continuous use. The 1. Continuous flow features: Endometrium is easy to bleed.
set of hysteroscope becomes very light and easy to carry When hysteroscope is inserted, its tip may touch the cervical
because it need neither a long light guide bundle nor a canal or endometrium and cause bleeding, which may lead
heavy cold light source. distending fluid sanguinolent and obscure the observation.
4. Flexible video hysteroscope: This is a total flexible fiber Therefore, in general, hysteroscopy would not be done if
hysteroscope with the light conducted by fiber bundles there is abnormal uterine bleeding or menstruation. In order
and the images transformed into RGB digital signals by to solve this problem, when doing hysteroscopy, uterine dis-
mini-CCD which is fixed to the rear of fiberscope. Then tending fluid will be frequently renewed if tainted with intra-
the digital signals are transmitted into processor for pro- uterine blood. The continuous flow outer sheath can be
cessing through wire lines. Therefore there are two main assembled surrounding the insertion tube of fiber hystero-
advantages: the first is that it does not apply fiber bundles scope. When the uterine distending fluid flowing into the
for transmitting images, thus could provide superior qual- uterine cavity through the inflow channel reaches the fundus,
ity images as that achieved from rigid telescope, as well it will flow along anterior, posterior, and both lateral walls of
as avoids the defect that a black point will appear on the uterine cavity to cervical canal, and then flow out of the body
image when a fiber is broken. The second is that the front from the gap between telescope and outer sheath.
tip of this hysteroscope can bend up and down as other 2. Increasing rigidness of the fiberscope: When equipped with
fiberscope. The outer diameter of insertion tube is 3.8 mm a rigid continuous flow outer sheath, the fiber hysteroscope
(Fig. 2.15). is made into a rigid one, which can be inserted into the uter-
ine cavity by force and reaches the target location. If there
In 1997, Japanese scholar Lin Baoliang developed a con- is trouble in inserting the telescope, only fiber hysteroscope
tinuous flow outer sheath (Fig. 2.16) and changed the history can be sent into the uterine cavity for observation under the
of fiber hysteroscope, thus making the fiber hysteroscope protection and guidance of the outer sheath.
into an era of continuous flow system. This continuous flow 3. Easy to handle the fiber hysteroscope: Continuous flow
outer sheath has two kinds, flexible and rigid. Their functions outer sheath is installed with a control handle, which is
are as follows. convenient for holding.
4. Diagnostic flexible hysteroscope using Lin polyp snare middle rigid part can be used to hold the scope, and can
system: For endometrial polyps which are detected by do 180° left/right shaft rotation. The semi-rigid part of the
diagnostic flexible hysteroscope in the office, a traditional rear segment can do 45° bending in all directions and free
management is curettage with requirements of cervical fixation. The operator can take advantage of these func-
dilation and anesthesia. Another treatment is to perform tions to insert mini-instruments into the working channel
management by changing the diagnostic hysteroscope to for treatment in a relaxed posture.
an operative one. However, the operative hysteroscope is
larger and also needs cervical dilation and anesthesia. It Usually, the diameter of flexible forceps used for thera-
has been an ambition to hysteroscopic surgeons for a long peutic hysteroscope is 1.8 mm, two are commonly used.
time that endometrial polyps could be removed at the
time of being discovered with diagnostic flexible hystero- 1. Biopsy forceps: Intrauterine tissues are taken under the
scope. In 2011, Lin polyp snare system was developed to direct vision of hysteroscope for pathological exami-
resolve this problem. When an endometrial polyp is nation. Because of small blades and very small sam-
detected by a diagnostic flexible hysteroscope in the ples, pathological examination is often far from
office, it can be simultaneously removed using a Lin satisfactory.
polyp snare system under direct vision of hysteroscope 2. Grasping forceps: It is used to take out the intrauterine
without requirements of cervical dilation and anesthesia foreign bodies or remove the IUD. The forceps can only
(Fig. 2.17a, b). clamp the tail string of the IUD because it is too small to
hold an IUD.
2.2.1.2 Therapeutic Fiber Hysteroscope
These traditional flexible forceps are very small and can
The telescope is equipped with a working channel, through
do very little work. Japanese Lin’s flexible forceps include
which a biopsy forceps or a grasping forceps can be inserted.
Therefore, a biopsy can be done by a pair of biopsy forceps
under direct vision or an intrauterine foreign body or IUD
can be removed by a pair of grasping forceps. Therapeutic
fiber hysteroscope has two types as follows.
1. Flexible therapeutic fiber hysteroscope (Fig. 2.18): It has

4.9 mm outer diameter of the front tip, 120° field of view,
100° up/down angulation, and 2.2 mm diameter of work-
ing channel.
2. Soft and rigid therapeutic fiber hysteroscope (Fig. 2.19):
The front section of telescope is soft and flexible, the
middle rigid, and the rear semi-rigid. In addition to the
above advantages of total flexible fiber hysteroscope, the Fig. 2.18 Flexible therapeutic fiber hysteroscope
a b
Fig. 2.17 (a) Lin polyp snare system. (b) The snare is extended from the hysteroscope
16 X. Liu et al.
2.2.2 Rigid Hysteroscope
Such hysteroscope has a rigid appearance, consists of an

outer sheath, inner sheath, and telescope itself. The rigid
telescope is composed of lens transmitting images and optic
fibers delivering light. It is easy to manipulate, suitable for
beginners, but one should be very careful of uterine perfora-
tion any time. According to its function, rigid hysteroscope
can be divided into two types as the following.
2.2.2.1 Diagnostic Rigid Hysteroscope

The diameter of the telescope is 2–4 mm, and the diameter of
the outer sheath supporting its use is 3–5 mm, which is exclu-
sively used to examine the uterine cavity. It can be done in
office and does not need anesthesia, dilatation of the cervical
canal, and grasping cervix with clamps. A 30° oblique view-
ing telescope is preferred to observe the uterine cavity, and
dilation of cervical canal is needed when a continuous flow
hysteroscope with 5.5 mm diameter outer sheath is used.
2.2.2.2 Therapeutic Rigid Hysteroscope

A 4.5 mm therapeutic rigid hysteroscope with continuous
irrigation is made up of 30° and 3 mm optical tube, and the
tubal sheath. Its 4.5 mm outer diameter makes examination
of uterine cavity possible without dilation of cervix. Its 30°
wide-angle scope allows to observe two tubal ostia and the
Fig. 2.19 Soft and rigid therapeutic fiber hysteroscope whole uterine cavity simultaneously by rotating the tele-
scope. The design of double valves and double sheaths
ensures smooth and continuous irrigation, and always a
clear vision. On this basis, if equipped with a 6.5 mm outer
sheath, it is a standard 6.5 mm therapeutic hysteroscope.
There is a 2.2 mm operating channel on the outer sheath,
and treatment can be done if inserting hysteroscopic for-
ceps. 8 mm continuous flow operative rigid hysteroscope
consists of 30°, 4 mm telescope, the tubal sheath, working
channel, and operative instruments. It has a clearer vision,
elevating working platform, greater distention flow, and
2.2 mm operating channel (Fig. 2.21). The forceps can be
classified into rigid, semi-rigid, and flexible ones according
to its feature, and semi-rigid forceps is the most suitable for
intrauterine treatment. According to the purposes, operative
instruments can be sorted into biopsy forceps, grasping for-
ceps, and scissors, etc. A biopsy forceps can also be fixed
Fig. 2.20 Biopsy forceps
on the outer sheath of the hysteroscope or a special bending
device (Albarran bridge) is installed onto the hysteroscope
to adjust the direction of inserting a flexible forceps. This
biopsy forceps (Fig. 2.20), grasping forceps, and scissors. procedure requires to be done under anesthesia.
They are larger instruments and do not go through the work-
ing channel but are fixed at the front of scope. The use of 2.2.2.3 Mini-Hysteroscope
Lin’s flexible forceps improves the capacity of therapeutic Flexible hysteroscope can well meet the patients’ needs of
hysteroscopy. comfort during a minimally invasive surgery. The new
Fig. 2.23 Integrated hysteroscope
2.3 Instruments for Hysteroscopic

Surgery
Fig. 2.21 Therapeutic rigid hysteroscope
Xuegang Liu
At the beginning of hysteroscopic surgery, the pioneers, such

as Magos from Britain, Lin Baoliang from Japan, Xia Enlan
from China, used prostatic resectoscope or bladder resecto-
scope from department of urology to perform hysteroscopic
surgery. It was until 1992 that the hystero- resectoscope
Fig. 2.22 Mini-hysteroscope exclusive for gynecological surgery was developed.
1.9 mm mini-telescope system integrates advantages of both 2.3.1 Hystero-Resectoscope (Fig. 2.24)
flexible and rigid hysteroscopes: patients’ comfort improved
(thin outer diameter), easiness in cleaning (can have auto- Hystero-resectoscope for gynecological surgery originated
clave sterilization), and effective treatment (5Fr or 7Fr work- from urological resectoscope, and on this basis the shape and
ing channel) (Fig. 2.22). size of its outer sheath was modified and continuous flow
system was added in order to adapt to the operational charac-
2.2.2.4 Hamou Hysteroscope teristics inside uterine cavity (Fig. 2.24). Its whole length is
Hamou micro-contact hysteroscope is equipped with mag- 30–35 cm and working length 18–19.5 cm, and the working
nifying lens, which cannot only see normal object images, length of super-long hystero-resectoscope is 22 cm or
but also can magnify the object by 20 times, 60 times, and 26.5 cm, which can be used in enlarged uterus. The outer
even 150 times. The disadvantages are that the hystero- diameters of different hystero-resectoscopes are 21Fr
scope is too heavy, and one needs specialized knowledge (7 mm), 24Fr (8 mm), 25Fr (8.3 mm), 26Fr (8.7 mm), 27Fr
about intrauterine pathology when doing contact (9 mm), and 28Fr (9.3 mm), respectively.
hysteroscopy.
2.3.1.1 Telescope (Fig. 2.25)
It provides a panoramic view with diameter 3 mm or 4 mm
2.2.3 Integrated Hysteroscope and depth of focus 30–35 mm. Angle options of different
objective lens are 0°, 12°, and 30°, with visual field 70°–
With the development of hysteroscopic technique, the 120°. The modes of 12° and 30° are commonly used so as to
instruments used for hysteroscopy are also in constant observe the uterine cornua and lateral walls easily. The
progress and are being perfected. In the minimally inva- 21/24Fr (7/8 mm) hystero-resectoscope is equipped with a
sive surgery, flexible hysteroscope can well meet the 3 mm telescope, with the others 4 mm telescope. The eye-
patients’ needs for comfort, but there is a slight defect in piece has an insulated shaft which can be connected to a
treatment. Now, integrated hysteroscope (Fig. 2.23) inte- teaching scope, a camera, a video camera or an adapter.
grates the double advantages of both flexible and rigid hys-
teroscopes, and its thin diameter elevates greatly the 2.3.1.2 Working Element (Fig. 2.26)
patient’s comfort, simple ways of sterilization make it It is an elastic hand control mechanical device, which can
easier to clean, and operative channel meets the need of control the operation of electrode. There are channels for the
effective treatments. insertion of telescope and working electrode on it, and also
18 X. Liu et al.
Fig. 2.24 Hystero-resectoscope
Fig. 2.27 Hysteroscopic sheath
Olympus and the like have special video camera for electric
resectoscope with panoramic view.
2.3.1.3 Hysteroscopic Sheaths (Fig. 2.27)

The resectoscope has two concentric circular sheaths to
introduce working element. The outer sheath and the inner
sheath can rotate between each other and prevent damage to
the cervix.
Fig. 2.25 Telescope
1. Outer sheath: Its diameter is 8–9 mm and there are sieve
holes at its front end and a stopcock at the rear end for
fluid outflow.
2. Inner sheath: Its front beak is embedded with oblique
ceramic insulation, and its rear end is fitted with a stop-
cock for fluid inflow. The design of the oblique ceramic
insulation greatly increases the effective irrigation of the
telescope and its durability, and can prevent leakage of
electricity. Olympus ABS (anti-blocking system), which
was a patent, integrates a micro-hole in the inner sheath
Fig. 2.26 Working element
of hystero-resectoscope (Fig. 2.28), and ensures a certain
amount of distention flow even if the irrigation holes are
blocked by tissues, thus a smooth operation is possible.
the connector connected with a high frequency current gen-
erator. Since the telescope has fore oblique angle, thus when After the inner sheath is inserted into the outer sheath, the
installed, the port of light source should be upward and elec- irrigation fluid flows from the tip of the inner sheath into the
trode downward. And the direction of the electrode port may uterine cavity and makes it distending, and then retunes via
also be upward or sideward. When fingers are pulling on the the sieve holes of the distal end of the outer sheath into the
trigger, the working electrode may move forward or back- gap between the outer and inner sheaths. The gap between
ward. The hystero-resectoscope adopts a passive rebound the inner and outer sheaths is very small, and this design is to
device with the resting position of electrode inside the sheath. reduce the resistance of water inflow and slightly elevate
When pulling the trigger by hand, the electrode tip moves resistance of water outflow. The continuous flow resecto-
out of the sheath and then moves back into the sheath by the scope allows a great deal of low viscosity distending medium
force of the spring. The cutting is to be done when the elec- to flow continuously and rapidly, thus maintaining a proper
trode tip is returning to the sheath. The electrode may move pressure and a moderate distention of uterine cavity. The
30–40 mm within the visual field of hysteroscope. It should vision becomes clear and the visibility is increased. There
be paid attention that only when operation field is totally in was a hysteroscope applying intermittent irrigation, which
sight and the electrode tip is on the way back to the sheath, had only one sheath and might be used with high viscosity
electricity current may be powered on. At present, only distending medium.
Fig. 2.29 Wire loop electrode
Fig. 2.28 ABS (anti blocking system)

Fig. 2.30 Forward angled loop electrode
2.3.1.4 Obturator
It is the core of the sheath with its head oval-shaped. It can
close the window of the beak of resectoscope, and suits the
shape of cervical channel for an easy insertion.
2.3.2 Active Electrodes
The resectoscope is often used with a monopolar electrode

and the power is 70–100 W.
2.3.2.1 Wire Loop Electrode

It is also known as wire loop electrode (Figs. 2.29 and 2.30),
and has two types, open (U-shape) and closed (O-shape),
with different angles like 0°, 12°, and 30°. 12° open wire
loop appears to be vertical, usually 6.2 mm wide and 4.1 mm
deep, which is mainly used for resection of endometrium,
cutting and removal of myomas and polyps. 0° open wire
loop electrode is used for incision of uterine septum and
splitting large myomas so that they may be clamped out eas-
ily. 21Fr (7 mm) resectoscope adopts closed wire loop
(Fig. 2.31), and this small wire loop is very suitable for the Fig. 2.31 Closed wire loop electrode
resection of small polyps, division of intrauterine adhesions,
resection of uterine septum, and removal of intrauterine for-
eign bodies. 2.3.2.3 Roller Ball Electrode
Its diameter may be 2 mm or 3 mm (Fig. 2.33). It can rotate
2.3.2.2 Needle Electrode (Fig. 2.32) around the axis with focused current and is mainly used for
It is suitable for cutting uterine endometrium and myome- coagulation of bleeding or ablation of uterine
trium, removing intramural myoma by fenestration. endometrium.
20 X. Liu et al.
Fig. 2.34 Roller barrel electrode

Fig. 2.32 Needle electrode
Fig. 2.33 Roller ball electrode
2.3.2.4 Roller Bar/Roller Barrel Electrode Fig. 2.35 Vaporizing electrode

(Fig. 2.34)
There are different sizes of roller bars, like 2 mm, 3 mm, 2.3.2.6 Band Electrode (Fig. 2.36)
and 5 mm, which may rotate around the axis. It has a It is similar to open wire loop, but wider, using pure cutting
wider contact surface than roller ball electrode, and is current and 200 W power. It shares the advantages of the wire
more suitable for endometrial ablation and coagulation of loop and the vaporizing electrode, and there is no bleeding
bleeding. when resects endometrium and other tissues. In addition, the
tissue resected can be sent for histopathological examination.
2.3.2.5 Vaporizing Electrode/Vaportrode
(Fig. 2.35)
Vaporizing electrode appears to be groove-shaped with the 2.3.3 Accessory Instruments and Equipment
working power 200 W, which is different from the electrodes
above and may be used to vaporize endometrium and small The accessory instruments and equipment include a catheter,
intrauterine myoma. vaginal speculum or hammer, vaginal retractor, cervical
clamps, cervical dilator, myomas grasping forceps, polypus special multifunctional high-frequency current generator
forceps, oval forceps, a curette, uterine suction head, suction (Olympus SurgMaster Electrosurgery Generator)
tube, and uterine suction cart, etc. Complex operations (Fig. 2.38). SurgMaster high-frequency electrosurgery
should be monitored by ultrasonography and (or) generator is equipped with the resection mode in saline,
laparoscopy. and when combined with transcervical resectoscope in
saline, plasma electric resection may be done. Compared
with conventional monopolar operation, SurgMaster gen-
2.3.4 Plasma Bipolar Resectoscope (Fig. 2.37) erator can use high frequency energy to convert the saline
into electron plasma with a high density of free electric
The plasma bipolar resectoscope allows the surgeon to particle for precise cutting of tissue. In addition, the
perform transcervical resection in saline (TCRis), with a decrease of heat conduction can reduce coagulation depth,
thereby reducing the tissue charring. And there is no need
to take the risk of conventional high-frequency monopolar
resection.
Clinically, TCRis has the following characteristics:
• Cutting in saline can be done without TURP syndrome,

and super large tissues can be removed;
• Bipolar current, which goes only through the local part of
patient’s body without hazard of burning;
• Safe for pacemaker;
Fig. 2.38 SurgMaster multifunctional high-frequency electrosurgery

Fig. 2.36 Band electrode generator
weight: 112 g→83 g, total weight: 248g
add 11.5 mm, total working length: 194 mm
8.5 mm Cutting group has same quality and

outer sheath is oval–shaped
26 Fr.
194 mm
248 grams
Fig. 2.37 Plasma bipolar resectoscope, also known as transcervical resection in saline (TCRis)
22 X. Liu et al.
• Avoidance of obturator nerve reflex;

• Accurate resection of the tumor (using a small wire loop),
especially mosslike floating tumor;
• No tissue adhesion, no need to clean up, and cutting more
smoothly;
• Decreased depth of thermal tissue damage with no char-
ring, and convenience for pathological examination;
• Clean operating surface, and more accurate tissue
identification;
• Bipolar current, accurate coagulation, and more
reliability;
• First choice for Diabetic patients.
2.4 Cleaning, Sterilization,

and Maintenance of Hysteroscopic Fig. 2.39 Specialized storage box for instruments
Instruments
Yan Quan and Xuegang Liu into the channels with a compressed air gun or a syringe to
flush out water. Finally, wipe the surface of hysteroscope and
With the continuous development and improvement of its accessories to keep the channels dry.
micro-mechanical, electronical, and optical instruments, Different kinds of hysteroscopic operative instruments, such
the instruments and equipment for hysteroscopy are also as biopsy forceps, scissors, foreign body forceps, and grasping
increasingly renovated, and become widely varied. forceps, must be cleaned after being used. Open each stop-
Because of their high accuracy and complex functions, cock, clean the interior of the channels using cotton swabs or
their proper cleaning, sterilization, and maintenance can special cleaning agents for hysteroscope; scrub the holes and
not only ensure the successful diagnosis and operation of grooves of instruments using a long thin brush or cotton swabs,
hysteroscopy, but also is critical to avoid the potential brush the joints of forceps using special soft brush. After clean-
complications. ing, the instruments should be inspected carefully and routinely
to see whether or not the lens is cracked, the sealed end has
infiltration of water droplets which blur the lens, the jaws of
2.4.1 Cleaning and Inspection forceps is misaligned, the insulated part has abrasion, the tele-
of Hysteroscopic Instruments scope is broken; and rubber washer is broken and damaged,
etc. After inspection, the instruments are wiped dry, and placed
One should keep in mind being gentle is very important in a special box for spare use (Fig. 2.39).
when cleaning the hysteroscope and its accessories. The cleaning and inspection of instruments is a critical
After the operation, place the instruments in cleaning factor affecting the operation, therefore, a person should be
solution, and be sure not to hit, fold, and press. Then disas- specially assigned to be in charge.
semble all the instruments completely and clean all the blood
clots and mucus deposits inside the channels with a special
brush or a cleaning gun. As for the cleaning of the exterior 2.4.2 Sterilization Methods for Instruments
surface of endoscope, one can use soft scrubs to brush clean of Hysteroscope
the telescope and its head, especially the lens of hystero-
scope. There should not be any residual components in order Hysteroscopic telescope and its accessories are a set of
that the lens is kept clear. If the lens is blurred, cleanliness sophisticated and expensive optical devices, including cylin-
can be done by scrubbing it with mixed solution including drical lens system, light-guide fiber, and lighting system.
ethanol and diethyl ether (95% ethanol 7 mL + ether 3 mL). Sterilization methods recommended currently are as follows
When wiping the lens, it is proper to use lens paper or soft and can be chosen depending on the situation. Before steril-
gauze. ization, first open each stop-cock of the sheaths, coil up the
After cleaning, place the hysteroscope and its accessories light guide bundles, and inflow/outflow tubes. Cables and
in a rinse sink, and rinse the channels with flowing water for tubes cannot be folded and all channels should be kept open.
at least 10 s. Then wash the surfaces of hysteroscope and all All instruments should be put in a specialized sterilization
instruments and accessories with flowing water, insufflate air box (Fig. 2.40).
peroxide (H2O2), active oxygen atoms (O), active hydro-

gen atom (H), etc. These active ions and abundant ultra-
violet (UV) radiation have a high thermal kinetic energy,
so that it can greatly increase the effectiveness on micro-
protein and nucleic acids, and kills the microorganisms in
a very short time so as to achieve the aim of sterilization
for instruments.
Low temperature hydrogen peroxide plasma steriliza-
tion system is based on the above intrinsic properties of
plasma. At low temperature (lower than 60 °C) and vac-
uum state, a regular plasma field is created in the steriliza-
tion chamber under the influence of high-frequent
electrical field. During this procedure, abundant UV radi-
ation is generated, which can directly damage the genetic
materials of microorganisms. Photolysis of UV radiation
breakdowns the chemical bonds of microbe-molecules,
and finally generates volatile compound. Through the
effect of plasma etching, free radicals within the plasma
Fig. 2.40 Sterilization box for flexible hysteroscope
field are capable of interacting with nitrogen/hydrogen
and nucleic acid of microorganisms, which may inacti-
vate the microorganisms and disrupt the metabolism of
microorganisms.
No toxic product remains after the use of hydrogen
peroxide, eliminating the need for ventilation and drain-
age. Nowadays, it is a widely used low temperature ster-
ilization method (Fig. 2.42).
2. Ethylene Oxide (EtO) sterilizer: The mechanism of EtO
killing varies microorganisms is alkylation reaction,
which can alkylate free radicals of protein including car-
boxyl (-COOH), amino (-NHZ), sulfhydryl, and hydroxyl,
leading to disruption of normal biochemical reaction and
metabolism of protein, resulting in the death of microor-
ganisms. Ethylene glycol (EG), a secondary product of
EtO after hydrolyzing, can also be used as a sterilizing
agent. However, the shortcomings of EO are that it needs
Fig. 2.41 Autoclave
2.4.2.1 Autoclave Sterilization

It is a preferred and the most reliable method for steriliza-
tion, and is recommended to use 2.3 bar
(1 bar = 105 Pa = 101.325 kPa, 1 kPa = 7.5 mmHg), 134 °C,
and 5 min for sterilization (Fig. 2.41).
2.4.2.2 Low Temperature Sterilization

1. Low temperature plasma sterilizers: Plasma is the forth
fundamental states of matter in nature except for solid,
liquid, and gas. It is generated by ionizing gas state of
matter under a strong electric field. Hydrogen peroxide
(H2O2) plasma, which is used as a media of sterilization,
includes a variety of active species such as hydroxyl radi-
cal (HO), hydroperoxyl radical (HO2), excited hydrogen Fig. 2.42 Plasma sterilizer
24 X. Liu et al.
a long sterilizing time and is harmful to environment and 2.4.3 Arrangement of Device
human bodies (Fig. 2.43). and Instruments for Hysteroscopic
3. STERIS low temperature rapid sterilizer: It uses peracetic Surgery
acid as sterilizing agent to damage the microorganisms
by changing the pH value or killing them by high oxida- Video monitors, uterine distending pump, and irrigating
tion. There are no toxic residuals on instruments after medium are put in the appropriate place, with ultrasonogra-
sterilization, and the second-product is not harmful to phy machine placed in the opposite side. After the power is
humans, but has corrosive and bleaching effect. switched on, all devices are at “ready” state. Then connect
To use STERIS, the instruments should be rinsed by them with the camera head, power cable, uterine irrigation
sterilant repeatedly for 30 min with the sterilization tem- tubing, electric cable for resectoscope, and negative plate.
perature at 45 °C (Fig. 2.44a, b). Put in the distention medium, of which 0.9% normal saline
and mannitol are often used. At the first time of using the
Light guide bundles, adaptors, and accessories can be dis- telescope, white balance should be adjusted after the scope
infected by scrubbing their surfaces with a piece of 75% is connected with camera to ensure that the clarity of the
alcohol-dampened gauze, or dressed in a sterile disposable scope is in the best condition. Record patients’ name, age,
plastic suit to isolate for sterilization purposes, but the con- medical history, and operation name with a specialized
tact area should still be scrubbed with alcohol. image-text workstation. When using a monopolar resecto-
The video camera head can be sterilized through scrubbing scope, switch on the electric generator after a negative plate
with alcohol or dressing in a sterile disposable plastic set. being well placed and then set the power at 80 W for resec-
tion and 60 W for coagulation. When using a bipolar, the
generator is switched on and set at plasma mode.
Sterilized instruments, such as telescope, cutting loop, roller
ball, working elements and obturator, are placed on the instru-
ment table, assembled together, and then connected with the
video camera and optical cable carefully. Use the sterilized gauze
to wipe the telescope from the object lens to eyepiece. Then
place them on the instrument table in order of use (Fig. 2.45).
Lay the patient in lithotomy position, disinfect her vulva
with 0.5% iodophor, and then spread aseptic towels over legs
and hips. When the operation begins, pay attention to the
supply of distending medium, and make sure there is no stop
of flow and no air embolism occurs. At the same time record
the amounts of fluid inflow and outflow. When the amount of
inflow exceeds far too much the amount of outflow, the sur-
geon should be alerted that TURP syndrome might occur
Fig. 2.43 Ethylene Oxide (EtO) sterilizer
(Figs. 2.46, 2.47 and 2.48).
a b
Fig. 2.44 (a, b) Low temperature rapid sterilizer for Endoscope

Fig. 2.45 Whole set of cervix-dilator (No. 4–12) Fig. 2.47 Connection of distention medium with irrigation tubing
Fig. 2.46 Sterilized irrigation tubing Fig. 2.48 Layout of hysteroscopic devices
2.4.4 Maintenance of Hysteroscopic tending pump, and high-frequency electric generator, etc.
Equipment Because the performance and purposes of different equip-
ment varies, so its maintenance must be done in accordance
As there are various kinds of hysteroscopes, the common with the requirements listed in the instructions, and only the
features will be generalized in this section so as to enable the common features of these equipment are singled out for
user to master principles of maintenance. description.
2.4.4.1 Optical Lens 1. The power supply used must be consistent with power
There are lots of optical products in the hysteroscopic opera- 220 V and 50 Hz specified in the instructions, and ground-
tive system, such as endoscopic lens, camera system, and con- ing power socket must be reliable.
denser and filter built in cold light source, etc. It is absolutely 2. Hysteroresectoscope belongs to high frequency electrical
forbidden to touch or wipe the surface of these products with appliances, should be checked regularly each year, and its
fingers, but one should use absorbent cotton dipped in alcohol performance, electrode plates, and foot switch must be
and ether mixture to scrub gently, and avoid using rigid cloth monitored and checked by professionals to see whether
to wipe so as to prevent scratching and injuring lens. they are normal or not.
3. It is forbidden to move an equipment when it is on opera-
2.4.4.2 Electronic Equipment tion or run an instrument when its sheath is broken.
The electronic equipment in endoscopic operational system 4. The total power supply must be turned off when equip-
includes cold light source, video camera system, uterine dis- ment are not in use.
26 X. Liu et al.
2.4.5 Storage After Operation
After use, all instruments are immediately immersed in the

enzymatic solution for 30 min to dissolve blood clots and
residual tissues adhering to them. All blood and stains should
be cleaned, such as using a small brush to wash out blood
clots from the interior channels, rinsing each joint repeatedly
with syringes, scrubbing roller balls with a soft brush if there
are charring tissues.
Use the flowing water to rinse the telescope for 5 min so
as to wash out completely the distending fluid remaining on
the telescope and flush out any residues and blood stains.
Then wipe dry it with gauze. Take care to protect the eye-
piece and the object lens and avoid abrasion and collision.
The lens on eyepiece should be scrubbed with 70% alcohol
swab, thus preventing the damage to its surface.
The hysteroscope and instruments, after being cleaned
with the flowing water, are wiped dry with specified soft
cloth, with their surface blown dry. The water remaining
inside the channels and stop-cocks is blown dry as well.
Then place them in boxes separately. The telescope needs to
be placed into the scope case and kept in the box, then stored
and kept in the equipment cabinet by the person in charge
(Figs. 2.49 and 2.50).
Any patient with hepatitis B virus surface antigen posi-
tive should be arranged to be the last one in whole day’s
operations. After the operation, hysteroscope and its
instruments are immersed in 2% glutaraldehyde for 1 h,
then stored up according to the above requirements. Other Fig. 2.50 Storage cabinet for hysterscopic instruments
instruments and dressings are sterilized as anti-O-positive
routine. a variety of instruments and equipment. The lithotomy
To sum up, hysteroscopic surgery should be done in an position of operation bed should be firm and be ready to
operation room specialized for endoscopic surgery. adjust various angles. The nurses who assist in performing
Operation room should be relatively large to accommodate hysteroscopic operation must have specialized training
and strong responsibility. Not only should they have coop-
eration experiences in a routine operation, but also they
should command a comprehensive grasp of the use, steril-
ization and maintenance of hysteroscopic instruments.
Only when they have a loving heart for patients and a
highly responsible spirit, could they complete the coopera-
tive work very well in hysteroscopic operation.
Suggested Reading
Equipment for Hysteroscopy
1. Baggish MS. Establishment of a hysteroscopy program. In: Baggish

MS, Barbot J, Valle RF, editors. Diagnostic and operative hysteros-
copy. 2nd ed. St Louis: Mosby; 1999. p. 367–90.
2. Peng Y. Medical endoscope image transverse striation elimination
algorithm simulation. Comput Simul. 2013;30:417–20. Chinese.
3. Xia EL. Latest development of hysteroscopy. Chin J Pract Gynecol
Obstetr. 2000;16:180–2. Chinese.
Fig. 2.49 Storage box for hysterscope
Instruments for Hysteroscopic Diagnosis and Instruments for Hysteroscopic Surgery

Treatment
12. Glasser MH. Endometrial ablation and hysteroscopic myomectomy
4. Lin BL, Miyamoto N, Tomomatsu M. Development and clini- by electrosurgical vaporization. J Am Assoc Gynecol Laparosc.
cal application of flexible hysteroscope. Jpn J Gynecol Obstet. 1997;4:369–74.
1987;39:649–54. Japanese. 13. Magos AL, Baumann R, Turnbull AC. Transcervical resec-
5. Lin BL, Miyamoto N, Tomomatsu M. Development of the scope of tion of the endometrium in women with menorrhagia. Br Med J.
new resectoscope for women―application of transcervical resec- 1989;298:1209–12.
tion and endometrial ablation (EA). J Jpn Assoc Endosc Maternity. 14. Pantaleoni D. On endoscopic examination of the cavity of the
1988;4:56–61. Japanese. womb. Med Press Cir. 1869;8:26–7.
6. Lin BL, Tomomatsu M, Su L. Development and clinical application 15. Xia EL. Latest development of hysterscopy. Chin J Pract Gynecol
of new hystero-fiberscope. Jpn J Gynecol Obstet. 1988;40:1733–9. Obstetr. 2000;16:180–2. Chinese.
Japanese.
7. Lin BL, Ishikawa H, Komiyama M. Development of flexible outer
sleeve for hystero-fiberscope. Japan J Gynecol Obstet Endosc.
1997;13:169–72. Japanese.
Cleaning, Sterilization, and Maintenance of
8. Lin BL, Iida M, Yabuno A, Higuchi TY, Murakoshi Y, Iwata SK, Hysteroscopic Instruments
Zhao Y. Removal of Endometrial polyps through a small caliber
diagnostic flexible hysterosocpe using a Lin polyp snare system. 16. Laurey D, Luke J, Mayette B. Care and maintenance of hystero-
Gynecol Minim Invasive Ther. 2013;2:18–21. scopes and nursing procedures. In: Baggish MS, Barbot J, Valle RF,
9. Lin BL, Iwata Y, Valle RF. Clinical applications of Lin’s forceps in editors. Diagnostic and operative hysteroscopy. 2nd ed. St. Louis:
flexible hysteroscopy. J Am Assoc Gynecol Laparosc. 1994;1(4 Pt Mosby; 1999. p. 147–54.
1):383–7. 17. Ma W, He JF, Shen W, Wang X. Experimental observation on ster-
10. Murman RJ, Norris HJ. Endometrial carcinoma. In: Blaustein’s ilization effect of a desktop ethylene oxide sterilizer on medical
pathology of the female genital tract. 3rd ed. New York: Springer- instruments. Chin J Disinfect. 2013;30(1):25–6. Chinese.
Verlag; 1987. p. 338–9. 18. Winer W. Role of the operating room nurse. In: Sutton C, Diamond
11. Tanizawa O, Miyake A, Sugiki O. Revaluations on diagnostic MP, editors. Endoscopic surgery for gynecologists. 2nd ed. London:
hysteroscopy prior to operation of endometrial carcinoma. Jpn J WB Saunders; 1998. p. 38–40.
Gynecol Obstet. 1991;43:622–6.
Anatomy and Histology in Hysteroscopy
3
Enlan Xia
3.1 Anatomy of a Normal Uterus cycle in its color, thickness, and crease, and is related to the
degree of uterine expansion. Its color may be pale white,
The uterus is a hollow organ, inverted pear-shaped, and brown yellow, light pink, peach-pink, or dark red. Sometimes
located in the center of the pelvis. It is made up of three it is accompanied by small petechiae. Its thickness may grow
parts, the fundus, the corpus, and the cervix. The narrow por- to 5–6 mm at late secretory phase. The upper 2/3 of endome-
tion between the corpus and the cervix is called isthmus, and trium is the functional layer, which is shed and passed out of
its upper portion is internal orifice of the uterus, that is, ana- the body during menstruation. Inferior 1/3 adjacent to the
tomical internal os; the lower portion is histological internal myometrium is the basal layer, in which there is no periodic
os, which marks the transition from the endometrium to the shedding and a new endometrial lining from it grows after
endocervix. The size and shape of the uterus may vary with the menstruation.
age and fertility. The uterus of normal non-childbearing
women measures 7–8 cm in length, 4–5 cm in width, and 3.1.1.2 Myometrium
2–3 cm in thickness. The volume of uterus increases in It is the thickest layer of the uterine wall, approximately
women after parturition. The proportion of the uterus to the 10–15 mm in thickness. It consists of bundles of smooth
cervix changes with age. At adolescence, the corpus is as muscle fibers and a few intermixed connective tissues, which
long as the cervix; in women of child-bearing age, the length contain undifferentiated interstitial cells, macrophages,
of the corpus is about twice that of the cervix; in postmeno- fibroblasts, and mast cells. The muscular layers are four in
pausal women, the corpus and the cervix are equal in length. number.
1. Submucosal layer: It is a thinner layer, located under the

3.1.1 Uterine Corpus mucous membrane, mostly composed of the longitudinal
muscle fibers and intermixed with a small amount of cir-
The upper portion of uterus is broader, which is known as the cular and oblique muscle fibers. Conspicuous circular
uterine body or corpus. The dome-shaped upper portion is muscle fibers develop at the uterine cornua of fallopian
called fundus, the middle space is called the uterine cavity, tube.
which is shaped in an inverted triangle with upper part broad 2. Vascular layer: It is located 5–6 mm beneath the mucous
and lower part narrow. The structure of uterine wall is com- membrane and mostly composed of circular muscular
posed of three layers. fibers with fewer oblique muscle fibers, through which
there are plenty of blood vessels, called vascular layer.
3.1.1.1 Endometrium 3. Subvascular layer: It is located underneath the vascular
Endometrium lines the uterine cavity and is influenced by layer with the muscle fibers disposed longitudinally and
ovarian hormones from adolescence to menopause. It pres- transversely.
ents slightly differently with the changes of menstruation 4. Subserosal layer: It is located beneath the serosa and
composed of longitudinal muscle fibers.
3.1.1.3 Serosa
E. Xia (*)
It is also known as perimetrium, which covers the corpus and
Hysteroscopy Center, Fuxing Hospital, Capital Medical University, fundus of the uterus. The outer layer of the rest of the uterus
Beijing, China is fiber membranes.

30 E. Xia
3.1.1.4 Uterine Horn and Ostium about 1 to 2 mm; its glands are sparse and dispersed and the
of Fallopian Tube lumina are also small. The epithelial cells present low colum-
At either side of the uterine fundus there is a uterine horn, nar shape with cell nuclei oval-shaped. The stroma is loose
connected to each of the fallopian tubes, where the muscular with less cytoplasm. This period is the optimal time for hys-
wall is thinner, only 5–6 mm. The cornu is deep and funnel- teroscopy and surgery.
shaped when not expanded. When fully expanded, tubal
ostium is visible at its top end, but it is not necessarily at the
medial top end, sometimes slightly lateral. Most ostia appear 3.2.3 Late Proliferative Phase
to be round, oval, crescent-shaped, even astral. When uterus
does not expand fully, it appears to be a brown hole, and It refers to the eighth to the 14th day of the menstruation
contraction of fallopian tube can be observed occasionally. cycle. The thickness of endometrium becomes 3–4 mm; the
glands increases and are curved; the shape of the epithelial
cell is tall columnar; and the cell nuclei are long oval and lie
3.1.2 Uterine Cervix in the cell center. The endometrium presents pseudostratified
structure without secretion, with stromal proliferation.
The lower portion of the uterus is narrow and cylindrical in Sometimes small spiral arteries may be seen.
shape, called cervix. Its upper portion is the internal os of
cervix, which is round or oval in contour, and the edge of
which is neat or mildly irregular. The cervix varies in length 3.2.4 Early Secretory Phase
and width from person to person, and the proportion of the
uterine body to the cervix of an adult is 2:1. It refers to the 16th to the 19th day of the menstruation cycle.
At this phase, the endometrium gets thickened to 5–6 mm,
and the glands proliferate and dilate further with indented
3.2 Cyclical Changes in Endometrium appearance. The glandular epithelia change to simple short
columnar cells, and the presence of vacuoles below the
3.2.1 The Menstruation Phase nuclei is characterized.
It refers to the first to the fifth day of the menstruation cycle,

during which the endometrium is fragmented, and endome- 3.2.5 Late Secretory Phase
trial gland shrinks and is hydrolyzed. Disintegrated endome-
trium can be seen under hysteroscope, as well as the glandular It refers to the 20th to the 28th day of the menstruation cycle.
regeneration. During this period, the endometrium becomes reddish or
pink, and edematous. Exuberant glandular secretion can be
observed by microscopic examination, and there is secretion
3.2.2 Early Proliferative Phase within the glandular lumina, with the upper epithelium
incomplete, stroma edematous, and interstitial cells change
It refers to the sixth to the seventh day of the menstruation to decidual-like cells.
cycle. During this period, the endometrium is thinner, only
Effects of Preoperative Medication
for Hysteroscopy and Commonly Used 4
Drugs in Gynecology on Endometrium
Xiaowu Huang
4.1 Preoperative Medication 4.1.1.1 Pseudo-Pregnancy Therapy

for Hysteroscopy In 1953, Meigs first found that, during pregnancy, decidual-
ization might appear in the endometrial tissues outside the
During hysteroscopic surgery, particularly when the uterus is uterus, followed by liquefaction, necrosis, and absorption. In
distended with distention medium, the endometrial shedding 1956, Kistner began to apply synthetic progesterone in com-
fragments are prone to block the sieve holes of hysteroscopic bination with estrogen to elevate the hormone levels of serum
outer sheath, which may cause the blockage of return flow. to a state similar to pregnancy, called the pseudo-pregnant
Together with intraoperative bleeding, the operation view is therapy, and first reported its clinical effects in 1958.
hindered, which is not helpful for the operation to run The administration of low dose progesterone does not
smoothly. The preoperative administration of drugs can inhibit ovulation and the endometrium retains thickening;
make endometrium thinner, and endometrial blood vessels and that of high-dose progesterone could cause most wom-
decreased, thus achieve a good vision that facilitates the en’s endometrium to atrophy, but occasionally irregular
operation and shortens the operation time. Pretreatment with bleeding. Progesterone is tolerable for most women.
drugs was originally used for hysteroscopic endometrial Clinically, the commonly used synthetic progesterone is
ablation. In 2014, the French clinical guidelines indicated divided into two categories according to its basic structure.
that, pretreatment with drugs may achieve a good vision, but
cannot decrease the occurrence of complications, therefore it 1. Testosterone derivatives: Norethisterone is commonly
should not be considered as a routine use. taken orally with 5 mg, twice a day. It is clinically used
At present, pretreatment with drugs is mainly used for for the treatment of dysfunctional uterine bleeding. The
women who have submucous fibroids and menorrhagia. endometrium always manifests endometrial thickening,
Pretreatment with drugs may induce amenorrhea, which is yellow color, flocculent, and sometimes wave-like under
beneficial for the correction of anemia. In addition, some hysteroscope. The manifestations of endometrial histol-
drugs may decrease the volumes of the uterus and fibroids, as ogy are highly secretory, and even stromal decidualiza-
well as shorten the operation time. tion. This medication is rarely used in pretreatment.
Commonly used drugs for pretreatment and their mecha- 2. Progesterone derivatives: Medroxyprogesterone acetate
nisms are elaborated below. is often used orally with 30–50 mg, once a day. Its possi-
ble mechanism is to inhibit ovulation, which suppresses
the growth of endometrium and has a continuous but
4.1.1 Mechanism of Pretreatment with Drugs immature secretory response. If used for a long term, the
Prior to Surgery secretory phenomenon can be less obvious, the endome-
trium is atrophied, the gland is reduced and sometimes
Clinically, the basis for pretreatment of endometrium with disappears, and the stromal cells are fusiform. In addi-
drugs is nearly the same as the treatment of endometriosis, tion, progesterone has some anti-estrogen effects by stim-
including pseudo-pregnancy therapy, pseudo-menopause ulating the activity of 17β-hydroxysteroid dehydrogenase
therapy, and medical oophorectomy. and sulfotransferase resulting in turning estradiol into
estrone sulfate, which may be discharged quickly out of
X. Huang (*)
Beijing, China

32 X. Huang
the cell. Through the inhibition of estrogen receptor, pro- Raloxifene is a selective estrogen receptor modulator, and
gesterone can also reduce the biological effect of estrogen its known therapeutic role is to exert estrogen-like effects on
on target cells, thereby inhibiting the growth of the bone and cardiovascular system, increase bone density
endometrium. Its adverse effects are menstrual abnormal- and inhibit bone loss, but it may have an anti-estrogenic
ities, headache, abdominal discomfort, mental stress, and effect in breast and uterine tissues. Desogestrel is the third
loss of libido, etc. generation of new contraceptive drugs and is likely to replace
3. Oral contraceptives: It is clinically used for adjusting and norgestrel currently used.
reducing menstrual blood loss, which was reduced to
40% of that before medication from clinical report. Take 4.1.1.2 Pseudo-Menopause Therapy
the estrogen-progesterone components, short-acting oral Danazol is a synthesized derivative of 17alpha ethynyl tes-
contraceptives as example, its progesterone may resist tosterone, and its chemical name is (17α)-Pregna-2,4-dien-
estrogen continuously. By hysteroscopy the endome- 20-yno[2,3-d]isoxazol-17-ol. It can block the synthesis and
trium appears to be thinner, smooth, red-pink, or red- release of GnRH, FSH, and LH, and directly inhibits the syn-
yellow. Although their endometrial thickness is thinner thesis of ovarian steroid hormone. And it may also be com-
than that in ovulatory women, most patients’ estrogen bined with the sex hormone receptors of target organs, thus
stimulation could not be completely suppressed, the causing the endometrium to atrophy, and resulting in tempo-
endometrium still affects the hysteroscopic view, and the rary amenorrhea. That’s why people call the treatment with
basal layer is difficult to be destroyed during operation. danazol the pseudo-menopause therapy.
Its continuous use can cause decidualization and amen- Danazol cannot only inhibit the synthesis and release of
orrhea, resulting in pseudo-pregnancy. Because the indi- GnRH, FSH, and LH, suppress the activity of cholesterol
viduals respond to this medication is different, its cleavage enzyme and 3β-hydroxysteroid dehydrogenase, but
application as a preoperative medication is restricted. also depress the conversion of estrone sulfate (E1S) to estra-
However, the administration of estrogen-dominant long- diol (E2), which forms a low estrogen environment, and thus
acting contraceptives may cause endometrium to appear prevents the growth of endometrium. Studies have shown
to be proliferation or hyperplasia. By hysteroscopy, the that it can also inhibit the endometrial growth directly.
endometrium appears to be thickened or with uneven Application of danazol 200 mg, twice a day for 3 months can
thickness, and polypoid hyperplasia, wave-like, red-pink transform the endometrial hyperplasia into atrophic or pro-
or red-yellow in color are visible. This medication is not liferative endometrium. Read and Sharp reported that after
usually used as pretreatment. the application of danazol 200 mg, 3 times a day for 6 weeks,
the average endometrial thickness reduced to 1.2 mm; while
There were also some clinical reports on successful endo- in the untreated group, the average endometrial thickness is
metrial pretreatment with oral contraceptives prior to hys- 3 mm at the proliferative phase, 7 mm at the secretory phase.
teroscopic surgeries. Grow et al. reported that from the early Under hysteroscope, the endometrium appears to be atrophic
follicular phase, the patient took oral contraceptives with or mildly hyperplasia, similar to menopausal atrophic endo-
150 μg of desogestrel combined with 30 μg of ethinyl estra- metrium, being white or pink, and bilateral tubal ostia are
diol for 18–20 days. The thickness of endometrium achieved often visible.
4.1 ± 1.6 mm after pretreatment by ultrasonography moni- Taking danazol for a long time may affect the liver func-
toring, so they could be used for endometrial pretreatment tion, and taking danazol for 2 to 4 weeks will increase serum
before hysteroscopic surgery. In recent years, Cicinelli et al. glutamic pyruvic transaminase (SGPT) level. Generally,
carried out some studies to evaluate the effect of pretreat- SGPT level may decrease rapidly after stopping taking dan-
ment. From the first day of menstruation cycle, desogestrel azol, and return to normal 2–4 weeks later. Commonly,
was given orally combined with raloxifene vaginally 60 mg there are no abnormal changes in bilirubin and acid phos-
for 10 days. In another group, oral danazol was taken 200 mg, phatase. In addition, during the medication, one may have
3/day for 10 days. On the 11th day of the cycle, endometrial adverse reactions like increased sebum, voice coarsening,
thickness was measured by ultrasonography. The results hairiness, breast enlargement or reduction, hot flashes, and
showed that the application of desogestrel combined with excessive sweating. In a comparison study, danazol was
raloxifene was better than that of danazol group, and it is a given vaginally 400 mg/day. In another group, danazol was
fast, cheap, and satisfactory pretreatment prior to hystero- given orally 600 mg/day. The medication was taken for
scopic surgeries. 30 days in both groups. The results showed that the thick-
4 Effects of Preoperative Medication for Hysteroscopy and Commonly Used Drugs in Gynecology on Endometrium 33
ness of endometrium in vaginal group was thinner than that applied to reduce the size of fibroids, decrease the blood sup-
in oral group, with adverse effects less in vaginal group. ply, control bleeding, and improve the anemia (see Fig. 9.52,
Sect. 9.3, Chap. 9), so as to help the anemic patients with
4.1.1.3 Medical Oophorectomy prolonged bleeding to increase their hemoglobin level. It was
GnRH-analogs (GnRH-a) are similar to GnRH in structure, reported that after medication, the volume of the uterus could
can compete for the pituitary GnRH receptors. When the be reduced by 30% to 50% and that of the fibroid could be
pituitary GnRH receptors are all occupied and drained by reduced by 10% to 60%. It cannot only lessen the difficulty
GnRH-a, it may have a descending regulatory effect on the in surgery, but also reduce the intraoperative bleeding, both
pituitary, namely, the pituitary secretion of gonadotropins of which are beneficial to the operation running smoothly
decreases, thus the sex hormone levels secreted by the ova- and operation time shortening. Therefore, the occurrences of
ries decline significantly, the effect of which is similar to the TURP syndromes are reduced and more patients may
surgical resection of the ovaries, called medical oophorec- have the opportunity of treating uterine fibroids by the hys-
tomy. Commonly used drugs are leuprorelin acetate (trade teroscopic operation. The duration of drug administration is
name: Enantone), buserelin, nafarelin, goserelin, and usually 3–6 months.
triprelin. Campo et al. found that, for submucous myoma patients,
Only at the early period of the first administration, the the pretreatment with GnRH-a did not improve postoperative
GnRH-a can transiently promote the secretions of FSH, LH, short-term or long-term effects except those with severe ane-
and estrogen. Thereafter, due to the decline of the reactivity mia. After pretreatment, the uterus was contracted and the
of pituitary and ovary, the secretions of FSH, LH, and estro- cervix was narrowed, which caused difficulties in dilating
gen are inhibited. Take goserelin as an example. After admin- the cervix. The operation time was significantly longer than
istration of sustained-release goserelin with the dose of that of the untreated group. Clinical practices proved that this
3.6 mg for once, the levels of FSH and LH can decline below shortcoming could be overcome by placing laminaria tent
the basal values within 14 days and continue to be suppressed into cervix to soften it prior to operation. Most scholars
in the following 5 or more weeks. In healthy women and believed that GnRH-a could facilitate the removal of larger
patients with benign gynecologic diseases, the estrogen lev- fibroids by hysteroscopic surgery. Even so, at present the
els can be reduced approximately to the level in menopausal high prices of GnRH-a have limited its widespread clinical
women or women after gonadectomy. The first injection of applications.
goserelin 3.6 mg is commonly given at the late luteal phase The adverse effects of GnRH-a are due to its low estro-
and the second injection 4 weeks later. The operation is to be genic properties, including hot flashes, vaginal dryness,
done at the fifth to the sixth week. At the fourth to the fifth headache, loss of libido, and so on. These symptoms can
week, the estrogen levels are low enough to make the endo- be relieved or disappear after stopping taking medicines.
metrial thinning similar to that in menopause women, with The bone losses of lumbar spine and proximal femur are
the uterine volume reduced and the total endometrial area also the side effects of GnRH-a, which are apparent when
decreased. Under hysteroscope, the endometrium appears as the drug is used for 3 months or more. A study showed that
that of menopausal women. the related low estrogen symptoms could be lessened when
After comparing danazol with goserelin for preoperative the treatment was combined with the application of
medication prior to hysteroscopic surgeries, some scholars tibolone.
found that the pretreatment with goserelin had better endo-
metrial thinning, less bleeding, less absorption of disten- 4.1.1.4 Other Anti-Estrogen, Anti-Progesterone,
tion medium, and was better than that with danazol. There and Endometrial Growth-Inhibiting
was no difference in uterine dilation time between two Drugs
groups prior to operations. Another study showed that Gestrinone, a 19-nor-testosterone derivative, has some prop-
through fixing and slicing endometrial biopsy specimens, erties, such as agonistic interaction with progesterone recep-
and marking endometrial vascular epithelial cells with anti- tors, anti-progesterone, anti-estrogen, inhibition of FSH and
CD34 antibody, there was no significant difference in LH secretion, suppression of ovulation, and atrophy of endo-
microvascular density between the natural menopause metrium. It was first synthesized in 1965 by Roussel-UCLAF
endometrial atrophy and endometrial atrophy induced by and was the earliest oral contraceptives. It is now mainly
danazol and goserelin. used for treatment of endometriosis.
As for the cases with intrauterine fibroids over 5 cm, Laboratory studies showed that gestrinone in a weekly
intramural fibroids or secondary anemia, GnRH-a may be dose of 10 mg could result in the suppression of ovulation
34 X. Huang
and subsequent disturbance of the luteal phase formation. rently the pretreatment prior to operation could not be
The histological characteristics of endometrium under the abandoned. It is most apparent that the endometrial pre-
influence of gestrinone presented the features of secretory treatment is advantageous in choosing the size of cutting
phase after ovulation. Its therapeutic effect was dependent on loop. The 26 Fr (8.67 mm) hystero-resectoscope is suitably
high affinity to estrogen and progesterone receptors. Mettler fitted with 24 Fr (8 mm) cutting loop, and the cutting depth
thought that gestrinone could not cause the ectopic endome- is nearly 4 mm. When the endometrial thickness is less than
trial lesions to disappear completely, but might lead to a 1–2 mm, the basal layer can be completely resected once
pause of proliferative or secretory phase. Its ultrastructural for all, therefore, each site of uterine cavity can be cut only
characteristics showed intraepithelial lysosomal deformation once. So it is quick and easy to operate with a desired
with increases in its activities, numbers and sizes, which expectation. Others held that hysteroscopic surgeries
contained amorphous cell debris or lipid moieties. These should be performed at early proliferative phase when
presentations were similar to premenstrual liposomal endometrium was the thinnest. However, this scheme is
degradation in the endometrium. Its usage was twice weekly hard to put into practice for women with disordered men-
in a dose of 2.5 mg for 4 to 6 weeks. struation, because there is no way to predict the state of the
Gestrinone-induced side effects are less than that of dan- endometrium. After medication, the endometrium gets
azol, with better tolerability. The main side effects are amen- atrophied and thinner, and the absorption of distension fluid
orrhea, breast reduction, and acne, which are all moderate. during hysteroscopic surgery are less than that without pre-
Its price is higher than that of danazol. treatment, thus reducing the occurrence of the operative
In recent years, ulipristal acetate, a selective proges- complication—TURP syndrome, which is a series of severe
terone receptor modulator, was reported to be used as life-threatening systemic symptoms resulting from hyper-
pretreatment for hysteroscopic surgery. When comparing volemia and hyponatremia caused by absorption of a great
oral ulipristal acetate (5 mg or 10 mg) taken everyday for amount of uterine distension fluid into the blood circulation
3 months, with injection leuprorelin acetate (3.75 mg) system. Another scholar stated that after pretreatment with
taken monthly for three times, ulipristal acetate is not GnRH-a, low estrogen state might enhance the activities of
inferior to leuprorelin acetate in controlling uterine endometrium and cerebral Na+ and K+ −ATP enzyme,
bleeding in women with fibroids and menorrhagia. For decrease the patients’ susceptibility to hyponatremia, pre-
women receiving ulipristal acetate at a dose of 5 mg or vent the brain damage, reduce the levels of antidiuretic hor-
10 mg, the median times to amenorrhea are 5–7 days, the mone, and prevent the excessive absorption of distention
volumes of fibroids are reduced by 36%–42%, and the fluid, all of which formed the protective mechanism against
possibility of hot flashes is significantly decreased. For hyponatremia.
those receiving leuprorelin acetate, the median time to Endometrial pretreatment with drugs have some poten-
amenorrhea is 21 days and the volumes of fibroids are tial problems, that is to say, if the diagnosis is determined,
reduced by 53%. the operation should be done at a particular time after the
Most scholars believed that the ideal depth of hystero- medication; the patients also need to pay more for these
scopic endometrial resection involved the endometrium expensive drugs; and all of them have side effects. While
and 2.5–3 mm superficial muscular layer of the uterus. If the endometrial pretreatment with the suction aspiration
the lesions were resected or ablated superficially, which by negative pressure will neither be affected by menstrua-
cannot effectively destroy the functional layer of endome- tion cycle nor influenced by the time of operations, and
trium and blood supply underneath, recurrence would occur can be done on those who are reluctant to accept drug
easily after operation. The most optimistic outcome after therapy or with acute massive hemorrhage. Since there is
transcervical resection of endometrium is amenorrhea, but no need for medication, the patients’ economic burden is
currently it can only be achieved in 50%–62% of the women lightened, and the impact and the interference of the drugs
after operations. When goserelin is applied prior to opera- on the endocrine system are avoided, so it is a fast, simple,
tion, the average endometrial thicknesses before and after effective, and safe method of endometrial pretreatment,
treatment are 3.7 mm/1.9 mm, with the mean thickness which is applicable to a variety of hysteroscopic
ratio 2.7. For endometrial resection, Kriplani believed that operation.
the pretreatment with danazol was not necessary in improv- In 1997, Hugo et al. published a report about a proposal
ing the prognosis. Although the endometrial thickness after that the pretreatment with drugs should be unnecessary, but
medication is not relevant to the success or failure of sur- the mechanical pretreatment could get thin endometrium. In
gery, and thickened endometrium indicates its activity, cur- addition, it did not interfere with the operation view due to
the increase in bleeding during operation, and also would It was reported that the occurrence rate of endometrial
not cause the increase in the absorption of distention hyperplasia (thickness > 8 mm) after the postoperative appli-
medium. Moreover, the completion of uterine suction cation of TMX in postmenopausal women with breast cancer
needed only 2 min or less, which could reduce the endome- was 35.9% to 84%. Its histological characteristics were
trial thickness and expose the basal layer quickly and effec- nearly the same as those in normal women with endometrial
tively. Suction aspiration can cause the endometrium hyperplasia. While the occurrence rate in postmenopausal
thinning, which could be confirmed by histological studies. women who have breast cancer without medication and ordi-
Regardless of any period in the menstruation cycle, the suc- nary female population is only 0% to 10%. The occurrence
tion aspiration can remove almost all the functional layer rate of TXM induced endometrial polyp is 25% to 51%, and
and reduce the function named “protection barrier” of thick- its incidence is higher than that of untreated patients [(8%–
ened endometrium on the basal layer. However, some schol- 36%)/(0–10%)].
ars insisted that preoperative uterine suction might lead to Another study was reported on applications of TXM in
bleeding and incomplete uterine suction could affect sur- postmenopausal women who have breast cancer. Prior to
gery. For beginners, it is better to apply endometrial premedication, the endometrium was examined to exclude
treatment with drugs. endometrial lesions. During 60 months of follow-up after
taking TXM, the endometrium had pathological changes
in 30.4% of patients, most of which were simple hyperpla-
4.2 Nolvadex sia, and none of them was atypical hyperplasia. Therefore,
it is suggested that for postmenopausal patients with breast
Nolvadex is styrene derivative, also known as tamoxifen cancer, endometrial assessment should be done by vaginal
(TMX). It competitively inhibits the endogenous estro- ultrasonography before the application of TMX. If the
gen by binding to the estrogen receptor of target cyto- thickness of double layer endometrium is measured
plasma, and the receptor complex entering into the >4 mm, curettage or hysteroscopic biopsy under direct
nucleus, so the number of free estrogen receptors vision should be performed. If the lesion is found, corre-
decreases. At the same time, the receptor complexes are sponding treatment should be conducted, and close follow-
binding to DNA to inhibit the synthesis of the estrogen up of drug usage should be implemented. The patients
receptor, thus decreasing the number of the receptors and should be paid careful attention to any vaginal bleeding
having anti-estrogen effects. It is clinically applied to during medication; and also vaginal bleeding after the
postmenopausal women who have metastatic estrogen drug withdrawal.
receptor positive breast cancer as adjunctive therapy and Anastrozole and other aromatase inhibitors (AI) can also
palliative treatment. prevent the recurrence of breast cancer. Such drugs can play
Clinical and laboratorial study found that TMX had a role in affecting the synthesis of estrogen through the inhi-
weak estrogenic effects on bone and endometrium. Its bition of key enzyme required in estrogen synthesis—aroma-
mechanism has not been fully elucidated and may be asso- tase. Garuti G applied aromatase inhibitors for treatment of
ciated with continued low estrogen activity induced by the breast cancer, and found that the occurrence rate of endome-
TMX/estrogen receptor complexes. TMX may stimulate trial lesions was low, and it could reverse the endometrial
endometrial proliferation in patients, and its role may dif- thickening induced by TMX.
fer with the change of the peripheral estradiol concentra- Under hysteroscopy, the endometrium of TXM induced
tion. When the estradiol concentration is low, it shows a endometrial hyperplasia appears as thickening and edema
weak estrogen effect. As the estradiol concentration with unevenness, and polypoid hyperplasia visible, of which
increases, the anti-estrogenic effect becomes more out- the surface is smooth, soft, and elastic with the gland ostia
standing. And when the estradiol concentration reaches a visible. Sometimes hemorrhagic and necrosis spots with dif-
certain level, its inhibitory effect is reversed, and it shows ferent sizes can be seen. Endometrial polyps (Fig. 4.1a–c) is
a stimulating effect on endometrial growth, causing endo- oval or ligulate, with its surface smooth, usually white, pink,
metrial hyperplasia, and even cancerization. In addition, or purple. Sometimes tiny dendritic blood vessels can be
the change of endometrial proliferation induced by TMX seen with the regular appearances. In patients having endo-
in postmenopausal patients with breast cancer may vary metrial carcinoma, the endometrium manifests as fragile,
with time, long-term exposure to TMX can increase estro- being pale or yellow-dirtiness, with large and irregular blood
genic effects and sensitivity of estrogen on TMX in the vessels seen on its surface. Target biopsy should be done in
body itself. these cases.
36 X. Huang
a b
Fig. 4.1 (a–c) Endometrial polyps induced by TMX
4.3 Clomiphene pituitary to secrete gonadotropins, thus starting or inducing

the follicle growth. When follicle becomes mature, a suffi-
Clomiphene, also known as clomifene or Clomid, is chlo- cient amount of estrogen prompts a peak secretion of FSH
rotrianisene derivatives and similar to tamoxifen in structure. and LH to stimulate ovulation through the positive feedback
It competes with estrogen for receptor, blocks the negative effect to hypothalamus. It is clinically used in women who
feedback effect of endogenous estrogen in the hypothala- have ovulatory dysfunction infertility. However, clinical
mus, which leads to increase of GnRH secretion, prompts the observations found that ovulation rate was high after appli-
cation of Clomiphene, but the pregnancy rate was lower, expression of an endometrial proliferation antigen Ki-67,
which might be associated with its other effects. causing cell apoptosis of endometrial glands and the stroma,
Regarding endometrium, Clomiphene may not only com- the result is the thinning of endometrium under its long-term
petitively bind to estrogen receptor within endometrial target effects. After the placement of it for 1 year, under the light
cells to inhibit physiological effect of estrogen on the endo- microscope, the number of endometrial glands is decreased,
metrium and cause the endometrial glandular dysplasia, it with its shape cubical or flat, the stroma decidualized and the
may also inhibit the induced synthesis of estrogen or proges- blood vessels expanded.
terone receptors, affect normal reaction of endometrial LNG-IUS has little effect on the ovary, therefore the sig-
glands to progesterone concentrations in circulating blood, nificant reduction of menses and amenorrhea are mainly due
thus decrease the gland secretory function and endometrial to direct inhibition of local LNG on the endometrium, rather
decidual reaction ability, and further influence the endome- than suppression of ovulation. Only when LNG intrauterine
trial thickness. release is more than 50 μg/24 h, a complete suppression of
Hysteroscopy should be done in ovulation and secretory ovulation can be achieved, which influences the ovary func-
phase, combining with ultrasonography, histological and tion. When 20 μg/24 h LNG is released, ovulation is main-
immunohistochemical methods to comprehensively deter- tained in 85% of women using the LNG-IUS. Because the
mine the influences of drugs on the endometrium, so as to LNG-IUS can release the LNG into uterine cavity during a
guide proper clinical usage of drugs. Under hysteroscopy, long period, its clinical application has been developed from
the endometrium appears to have some nonspecific changes simple contraception into a variety of gynecological patholo-
including unevenness, local edema, and inconspicuousness gies, such as menorrhagia, endometriosis and adenomyosis,
of gland ostia in secretory phase. endometrial hyperplasia and atypical hyperplasia, and endo-
metrial protection, etc., with good effects.
To evaluate the efficacy of LNG-IUS compared with oral
4.4 Levonorgestrel-Releasing norethisterone acetate for treatment of simple and complex
Intrauterine System (LNG-IUS) endometrial hyperplasia in perimenopausal women, a ran-
domized controlled trial (RCT) was carried out and found
Levonorgestrel-releasing intrauterine system (LNG-IUS, that, after treatment for 12 months, the endometrial regres-
trade name Mirena) is a new intrauterine contraceptive sys- sion rate was 88.1% in the LNG-IUS group, and 55.7% in
tem which has been available since 1990s, and has been oral drugs group, with a significant difference achieved.
approved of application for contraception by more than 120 A prospective observational study was carried out on
countries. LNG-IUS consists of a T-shaped intrauterine con- administration of GnRH-a and Mirena for 6 months in 14
traceptive, with the main body a T-shaped plastic frame young women who had early-stage endometrial cancer and
(32 mm in length) and the vertical stem a steroid reservoir wished to preserve their fertility, and discovered that endo-
(50% in weight). The reservoir is 19 mm in length, contains metrial regression was found in eight women, progression of
a total of 52 mg Levonorgestrel (LNG) with polydimethylsi- the disease in four, and recurrence in two. Therefore, patients
loxane covering the outer surface, and is a vital part to con- should be adequately counseled prior to conservational treat-
trol the release of LNG. After the insertion of LNG-IUS into ment, and have close follow-up during and after treatment. In
the uterine cavity, it provides an constant release rate of hysteroscopic center of Fuxing hospital, Capital Medical
20 μg/24 h of LNG, which results in very high concentra- University, for young women who have atypical endometrial
tions in endometrium (470–1500 ng/mL). In contrast, the hyperplasia and eager to have children, a partial endometrial
concentrations are 1.8–2.4 ng/mL in myometrium and 0.1– ablation is performed just removing the functional layer of
0.2 ng/mL in serum. The local concentration is over a thou- the endometrium and maintaining the basal layer. High-dose
sand times higher than that in circulatory system. The high progesterone is given and a Mirena is placed in uterine cavity
local LNG concentration suppresses the growth of endome- for adjuvant therapy post-operation. After endometrial
trium, leading to atrophy of endometrial glands, and edema regression, active fertility treatment is conducted
and decidualization of the stroma. LNG can inhibit the (Fig. 4.2a–c).
38 X. Huang
a b
Fig. 4.2 (a) Hysteroscopic view after the placement of Mirena for (c) Hysteroscopic view of applying GnRH-a and Mirena for 3 months
3 months in women with complex endometrial hyperplasia. Endometrial after partial endometrial ablation in women with complex endometrial
histology: endometrial glandular epithelium is flat and the stroma is hyperplasia. Endometrial histology: decidualization of the endometrial
decidualized. (b) Hysteroscopic view of complex atypical hyperplasia. stroma
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Application of High Frequency
Electricity in Hysteroscopic Surgery 5
and Its Thermal Effects on Tissues
Hua Duan
In 1924, Wyeth first found that high power and high fre-
Active electrode
quency (HF) damped waves were able to incise tissues, and
then high frequency damped wave electrotome was devel-
oped and applied in surgery by Anderson et al. In 1928, High frequency power
Body tissues
Bovieh and Cushing developed a high frequency undamped
wave electrotome, which laid the basic foundation of high
frequency electricity in the surgical treatment. In recent
years, high frequency electricity has been proved to be safe, Return electrode
efficient, easily handled, and manipulated, and has been
widely used in hysteroscopic surgery and improved quickly. Fig. 5.1 Electrical circuit and its role
5.1 The Electronic Circuit Compositions high; but the return electrode has a larger contact area with
and Current Types in Hysteroscopic the body tissues, so the current density is relatively low.
Electrosurgery The changes of the temperature in human tissues are pro-
portional to the square of current density. Therefore, when
5.1.1 The Electronic Circuit Compositions the high frequency current passes, the temperature of human
in Hysteroscopic Electrosurgery tissues under the active electrode rises very quickly, while
less heat is produced at the negative plate, which can be
High frequency electrosurgery refers to that the electric cur- neglected. Thus, in a closed high frequency electrical circuit,
rent of a certain intensity runs under the set voltage through the electric cutting, electrocoagulation, electrocautery, or
the active electrode into the biological tissue to produce the other high frequency electrosurgery on body tissues are lim-
electrothermal effects and cause expected damage to the tar- ited to the areas in contact with active electrode, so that high
get tissues, thus achieving the purpose of treatment. As shown frequency electrosurgery could be done smoothly.
in Fig. 5.1, in high frequency circuit system of hysteroscopic Electrocautery is different from electrosurgery.
surgery, a part of the body tissue exposes to the median of two Electrocautery is to heat the metal conductor by electricity,
electrodes: one is an active electrode and the other is a return and then acts on the tissues. Through the physical transfer of
electrode (negative plate). In operation, high frequency cur- heat, the thermal destructive effect is achieved. Usually, the
rent runs in the direction of the arrow along the tissues. Since thermal effect temperature between the heated metal conduc-
there is only a narrow surface area between the active elec- tor and the biological tissues can reach 60 °C to 90 °C, there-
trode and the body tissues, the current density is relatively fore, it can only be used for coagulating tissues. However,
electrosurgery is to have high frequency current of a certain
intensity run under the set voltage through the active elec-
trode into the biological tissue, achieving the electrothermal
effect. The electrothermal temperature can be up to
100 °C–500 °C, thus the expected destruction and treatment
H. Duan (*) can be implemented to the pathological tissues.
Minimally Invasive Center, Beijing Obstetrics and Gynecology
Hospital, Capital Medical University, Beijing, China

42 H. Duan
5.1.2 Current Types in Hysteroscopic

Electrosurgery
The commonly used types of high frequency electrical cur-

rent in hysteroscopic operation are mainly cutting current
and coagulating current.
5.1.2.1 Cutting Current

The high frequency current that maintains a continuous out-
put and produces cutting effects on biological tissues in elec-
trosurgery is known as cutting current. The characteristics of
its wave pattern are continuous undamped sine waves. As
shown in the graph (Fig. 5.2), one may see that at a certain
voltage, the current is oscillating at an extremely high
frequency between the positive and negative electrodes. Due
to the continuous current output, the cutting current has rela-
tively higher average energy, and it also has no electric
Fig. 5.3 Wave pattern of coagulating current (pulse damped wave)
energy attenuation in the process of current output. When
this continuous, undamped high frequency current acts on
the biological tissues through the tiny active electrode (cut- 5.1.2.2 Coagulating Current
ting electrode in hysteroscopic operation), it produces an Contrast to the cutting current, the high frequency current
extremely high current density on local tissues so as to heat that changes the continuous output forms and produces
up the local tissue rapidly, and causes vaporization and cell coagulating effects on biological tissues is known as coagu-
rupture, thus producing the cutting effect. During the cutting lating current. Its wave pattern characteristics are intermit-
process, on the one hand, the intracellular heat is dispersed tent pulse damped waves (Fig. 5.3) and electric energy
by the cell rupture resulting from high temperature, which attenuation occurs in the process of current output. It is due
prevents the heat transfer and infiltration from the site with to the electric energy attenuation of the coagulating current,
high temperature to the adjacent tissues, producing “autono- the quantity of heat produced by tissues is reduced more sig-
mous cooling effect.” On the other hand, the high tempera- nificantly than the undamped current at the same voltage. In
ture carbonization of the tissue cells beneath the cutting electrosurgery, the roles of coagulating current include des-
surface increases tissue resistance and limits the conduction iccation and fulguration. When the coagulating current pro-
of electrothermal effects to the deeper tissues. duces coagulating effect through the contact of rollerball
electrode with tissues, because the contact area is larger than
that of the cutting current, the current density passing through
the contact surface is less than that of the cutting current.
Therefore, at a higher voltage output, a wide range of tissue
thermal damages may be resulted. Along with the increased
distance away from the active electrode, the temperature
conduction of its tissue thermal effect drops gradually. And
when the temperature is over 45 °C, the thermal damage to
tissue cells is closely related to the action time of the
electrode.
5.1.2.3 Blended Current

Since the cutting current is different from the coagulating
current in wave pattern characteristics, the electrothermal
effect on tissues is also different. Therefore, cutting tissues
combined with some coagulating current can often achieve a
better clinical effect. This blended current usually manifests
Fig. 5.2 Wave pattern of cutting current (continuous undamped waves) as blended damped and undamped waves (Fig. 5.4).
5 Application of High Frequency Electricity in Hysteroscopic Surgery and Its Thermal Effects on Tissues 43
60 °C, the enzymatic activity is obviously lower, and at

80 °C, the enzymatic activity is completely lost.
5.2.2 Influence of the Electrothermal Effect

on Uterine Tissues
The thermal damage to the tissues during hysteroscopic sur-

gery has been a focus of attention of gynecologic endoscopic
surgeons. Due to the complexity of the factors related to the
study, especially living tissue specimens are not easy to get,
the further knowledge of this issue is restricted. The scholars
Fig. 5.4 Blended wave pattern of cutting and coagulating current who studied the isolated uterine specimens and some living
uteruses drew the following conclusions: the depth of the
endometrial damage is not related to the power of the elec-
trode; there are variations in the depth of tissue thermal dam-
5.2 Electrothermal Effects age caused by different current waveforms; the tissue damages
in Hysteroscopic Surgery and Its are related to the action time of the electrode. Indman et al.
Impact on the Tissues carried out studies of the electrothermal effects on the uterus
in vivo and found that when the cutting current was 19 W and
5.2.1 The Changes in Tissue Cells Caused by 59 W, and the coagulating current was 57 W and 28 W, the
Electrothermal Effects depths of the thermal damage into the uterine myometrium
were 1.5 mm, 2.7 mm and 6.1 mm, 1.8 mm, respectively. Thus
5.2.1.1 Influence of Electrothermal Effect the depths of the tissue thermal damage caused by cutting and
on Protein coagulating current were different even at the same power.
Protein has high molecular weight and a complex composi- A clinical and laboratory study of electrothermal effects
tion and structure. The bond energy of secondary bonding on tissues during hysteroscopic surgeries was carried out in
(non-covalent) which maintains the molecular conformation the Hysteroscopy Center of Fuxing Hospital, Capital Medical
is relatively low, thus its molecular structure is unstable and University. Based on the study of isolated uterus, different
easily influenced by physical and chemical factors, leading current wave patterns were selected and different electric
to the destruction of its spatial conformation, change of its power and the action time were preset, then electric resection
physicochemical properties, decrease of its stability and or coagulation was performed on the endometrium and the
loss of the biological functions. All of them result in the myometrium hysteroscopically. The tissue specimens
denaturation of protein. High temperature can make the pro- obtained after operation were examined by histological and
tein molecules denatured by rupturing the secondary bond. histochemical methods to observe and analyze the correla-
Generally, protein denaturation may occur at 60 °C. However, tions among varieties of factors including the electric power,
the usual active cells may die by producing protein denatur- the action time, the thickness of the tissues by cutting or
ation when they are at the temperature of 600 °C for only coagulating, and the depth of tissue thermal damages, and to
1 s. study the histopathologic changes and the depth of electro-
thermal damages in uterine tissues by electrical thermal
5.2.1.2 Influence of Electrothermal Effect effect, as well as to discuss the changes in ultrastructure of
on Enzymes cells influenced by the electrothermal effect at the subcellu-
Enzyme is one kind of protein with catalytic properties pro- lar level under the electron microscope. The aims are to find
duced by active cells. In the metabolic process of the living the appropriate operation power setting and the depth and
organisms, almost every chemical reaction is induced by scope of tissue thermal damage under this set power, and to
some enzymes. Enzyme is biological catalyst, so enzyme- discuss the action rules and related mechanisms of electro-
induced reaction is similar to the general chemical reaction, thermal effects on tissues during hysteroscopic surgeries,
that is, the temperature increases, the reaction speed is quick- which can provide references and bases for clinical treatment
ened. However, the enzyme is also a type of protein, and will and the improvement of the safety and effectiveness of hys-
denature at high temperatures. When the temperature reaches teroscopic surgery.
44 H. Duan
5.2.2.1 Influence of Current Wave Patterns 5.2.2.3 Setting of Electrode Power

on the Thermal Damage to Tissues There is no uniform standard about the electric power set-
In this study, a variety of powers and action times with dif- tings in hysteroscopic surgery. The settings of electric pow-
ferent currents were set to work on endometrial tissues, it ers range from 30 W to 160 W with the power of resection
was found that at the same power and the action time, the larger than that of coagulation. According to the mechanisms
depth of the tissue thermal damage beneath the cutting of the electrothermal damage and the clinical requirement on
electrode was less than that of a coagulating electrode therapeutic effects, a minimum output power should be uti-
(P < 0.05). lized to achieve the expected therapeutic purpose. The clini-
cal studies in the Hysteroscopy Center of Fuxing Hospital,
5.2.2.2 Influence of Electrode Powers and Capital Medical University indicated that the depth of the
Action Times on the Thermal Damage uterine tissue thermal damage caused by cutting current was
to Tissues unrelated to the electric power and the action time (P > 0.05);
It was found from studies of the isolated uterus or hystero- when the minimum output power of cutting current was set
scopic surgery that, (1) at the preset power and the action at 60 W, it could achieve the aim of damaging the whole
time, the depth of thermal damage to the tissues beneath endometrial layer, but sometimes there might be a phenom-
the cutting electrode has no correlations to the electric enon that the electric wire loop sticks to the endometrium
power and the action time (P > 0.05); (2) in the isolated when performing the operation and the speed and the depth
uterus, the depth of thermal damage to the tissues beneath of resection might be affected when cutting lasts longer;
the coagulation electrode does not correlate with the elec- such phenomenon would be unlikely if the power was
tric power and is positively related to the action time; (3) increased to 80–100 W, whether the electrode action time is
in hysteroscopic surgery, the depth of thermal damage to long or short, therefore it was considered a suitable cutting
the tissues caused by coagulating current has significant power. The depth of the tissue thermal damage caused by
correlations with electric power and the action time coagulation current is closely correlated to the electric power
(P < 0.001), which is negative with the power and positive and the action time. Its correlation could be expressed by
with the action time. regression equation: Y = 2.666–0.021 (W) +0.723 (T)
The effects of active electrode of different power output (P < 0.001), namely, the depth of thermal damage is nega-
on thermal damage depth of uterine tissues can be seen in tively correlated to power, but positively correlated to elec-
Tables 5.1 and 5.2. trode action time. In our clinical studies, on the effects of the
Table 5.1 Thermal damage to the isolated uterus and its actual damage depth (mm, x ± s )
Endometrium Thermal damage depth Actual destruction depth
Type Power (W) Cases in total Removal depth Action 3–5 s Action 6–8 s Mean Maximum
Cutting 60 8 2.422 ± 0.106 0.328 ± 0.130 0.516 ± 0.102 3.109 ± 0.126 3.790
80 10 2.986 ± 0.341 0.375 ± 0.144 0.310 ± 0.082 3.824 ± 0.233 4.262
100 10 3.325 ± 0.084 0.402 ± 0.121 0.325 ± 0.221 3.819 ± 0.611 4.412
Coagulating 30 8 0.084 ± 0.013 2.643 ± 0.416 3.290 ± 0.422 3.325 ± 0.240 3.948
60 10 0.132 ± 0.066 2.763 ± 0.162 3.512 ± 0.625 3.610 ± 0.401 4.195
80 10 0.863 ± 0.147 1.963 ± 0.312 3.020 ± 0.160 3.284 ± 0.138 4.212
100 8 0.746 ± 0.211 2.041 ± 0.511 2.294 ± 0.242 3.016 ± 0.326 3.884
Note: In the table, the value of the average and maximum damage depth is taken from that of 6 to 8 s groups
Table 5.2 Thermal damage to the uterus in vivo and its actual damage depth (mm, x ± s )
Endometrium Thermal damage depth Actual destruction depth
Type Power (W) Cases in total Removal depth Action 3–5 s Action 6–8 s Mean Maximum
Cutting 60 10 2.047 ± 0.045 0.324 ± 0.125 1.075 ± 0.233 3.081 ± 0.302 3.632
80 14 2.683 ± 0.216 0.351 ± 0.142 0.536 ± 0.146 3.605 ± 0.423 3.993
100 12 2.465 ± 0.243 0.447 ± 0.156 0.532 ± 0.186 3.249 ± 0.526 3.920
Coagulating 30 11 0.035 ± 0.007 2.609 ± 0.516 3.474 ± 0.444 3.546 ± 0.520 4.160
60 13 0.101 ± 0.014 2.533 ± 0.310 3.118 ± 0.537 3.277 ± 0.534 3.788
80 10 0.362 ± 0.087 1.354 ± 0.318 2.144 ± 0.606 2.514 ± 0.665 3.537
100 8 0.519 ± 0.239 1.454 ± 0.551 2.106 ± 0.384 2.696 ± 0.485 3.338
Note: In this table, the value of the average and maximum damage depth is taken from that of 6 to 8 s groups
a b
Fig. 5.5 (a, b) HE staining
four preset coagulation electrode powers on uterine endome- Though some cells maintain the normal structure, the
trium, respectively, we found that at the same action time, the eosinophilic cytoplasm is increased, vacuole is formed,
depth of tissue thermal damage decreased as the power cell membrane disappears, and also nuclear pyknosis,
increased; at the same power, it increased as the action time karyorrhexis and karyolysis are present (Fig. 5.5a, b).
was prolonged. Thus 30–60 W should be a suitable coagulat- The above pathological changes are more apparent in
ing power. In the clinical operations, when the endometrium the coagulating group than those in the cutting group. The
is thicker or at a thicker position of the uterine wall, low cutting current does not make any differences in tissue
power active electrode can be used and action time prolongs, injury at different power and the action time, but in the
thus producing its effect of deep tissue thermal damage. coagulating group, the less the electric power is and the
However, if the location is prone to perforation, such as uter- longer the action time is, the more serious is thermal
ine cornua, fundus or a thin uterine wall, the electrode action damage to the tissues.
time should be shortened in order to avoid perforation or 2. NADH-d (nicotinamide adenine dinucleotide diaphorase)
even damage to adjacent organs. staining: With NADH-d staining, under the action of
electrode, the edge of the surface layer with tissue ther-
mal damage appears to be yellowish-brown. A thick col-
5.2.3 Histopathological Changes orless tissue strip is visible to the underlying layer. At the
of Electrothermal Injury bottom layer, the normal uterine smooth muscle cells and
the vascular smooth muscle cells are dark blue; between
5.2.3.1 Light Microscope the colorless tissue strip and normal deep blue tissue
Through light microscopic observation, the pathological strip, there is a thin pale blue staining region, which is the
changes in thermal tissue damage caused by cutting and transition zone for tissue injuries; the colorless layer of
coagulation current manifest as a thermal damage zone damaged tissue by coagulation is significantly thicker
which is made up of the coagulative and partial muscle than that by resection, and its thickness is different along
necrosis layer from the surface to the inside. The thermal with the different power and the action time. The tissue
damage zone beneath the coagulating electrode is deeper thickness of thermal damage by coagulation is the most at
than that under the cutting electrode. 30 W and the least at 100 W, but the thickness is the most
at 80 W and the least at 60 W by resection (Fig. 5.6a, b).
1. HE (Hematoxylin and Eosin) staining: With HE staining, 3. Masson’s staining: By Masson’s staining, the coagulative
the coagulative necrosis layer shows that the tissue struc- necrosis layer appears to be orange-red (necrotic smooth
ture is damaged and cell structure disappears, forming an muscle), and blue non-cell structure (extracellular collagen
amorphous eosinophilic pink substance. This layer is fiber) substance. The underlying partial smooth muscle
thicker in the coagulating group, while thinner in the cut- necrosis layer is orange-red denaturized necrotic muscle
ting group, intermixed with blue necrosis nuclear frag- fibers intermixed with the light blue collagen fibers. At the
ments. The characteristics of partial necrosis layer are that bottom layer, it is the pink muscle fiber bundles and deep
the amorphous necrotic cells coexisted with normal cells. blue intra-bundle collagen fibers (Fig. 5.7a, b).
46 H. Duan
a b
Fig. 5.6 (a, b) NADH-d staining
a b
Fig. 5.7 (a, b) Masson’s staining
5.2.3.2 Findings Under Electron Microscope equipment, easy operation, and abundant histopathologic
1. Tissue structure is destroyed by thermal energy, normal specimens obtained during the operation. Therefore, high
cell morphology disappears, only fragments without frequency electricity has become the superior therapeutic
shapes and structures can be seen. energy source and has been widely used in clinical practice.
2. A variety of ultrastructure abnormalities can be seen in
transition zone between necrotic zone and normal cells.
The changes in nucleus mainly manifest as nuclear pyk- 5.3.1 Application of Cutting Current
nosis, karyorrhexis, karyolysis, peripheral clumping of in Hysteroscopic Electrosurgery
heterochromatin, etc., while in the cytoplasm, vacuoles,
mitochondrial swelling, and endoplasmic reticulum Cutting current is widely used in gynecological endoscopic
expansion and degranulation develop (Fig. 5.8a, b). surgery. In recent years, hysteroscopic resection of endome-
trium in treatment of abnormal uterine bleeding has sub-
stantially replaced laser endometrial ablation. Cutting
5.3 Clinical Application of Hysteroscopic current can resect endometrial layer and its underlying
Electrosurgery superficial myometrial tissues, which can effectively pre-
vent endometrial regeneration. At the time of cutting, if
After comparing the outcomes of high frequency electrosur- appending some coagulating current, it can effectively
gery with laser operations, Gaillard et al. concluded that both coagulate the blood vessels in tissues underneath the cutting
techniques were similar, and that the electric energy had its surface to achieve a hemostatic effect. Some scholars
advantages, including being economical and cheap, simple believed that the clinical effect using cutting current was
a b
Fig. 5.8 (a, b) Transition zone between necrotic zone and normal cells
better than that using coagulating current. A cutting elec- 5.3.2 Application of Coagulating Current
trode could reach directly into the myometrium, which in Hysteroscopic Electrosurgery
might not only ensure the removal and destruction of the
endometrial glands, but also prevent its proliferation effec- Coagulating current is also an indispensable form of power
tively. Meanwhile, prior to operation, the endometrium did function in hysteroscopic surgery. Due to its strong ther-
not need to be pretreated with hormone, which could not mal penetration, it gets a wide range of tissue damage and
only reduce the cost of treatment, but also avoid the side good hemostatic effects. Moreover, it is also a relatively
effects of drugs. Almost all the resected endometrial tissues simple operation and has small technical difficulty. It is a
should be taken for histological examination. Some authors new approach of treatment for menorrhagia by endome-
reported that some endometrial lesions which were not sus- trial ablation resulting from its electric coagulation effects
pected before the operation were detected from the resected under hysteroscope. Its therapeutic effects are essentially
specimens, which included endometrial focal atypical the same as that of laser endometrial ablation, but its post-
hyperplasia and focal endometrial cancer. This indicated operative amenorrhea rate is not as high as that by laser.
that it helped to reduce the rate of missed diagnosis of endo- On the one hand the tissue penetrating capability of coagu-
metrial precancerous lesions and endometrial cancer. In lating current is less than that of laser; on the other hand
addition, the submucosal myoma of uterus and endometrial there are more factors that influencing endometrial destruc-
polyps can be resected continuously, without changing tion by coagulating current, such as the setting of electric
instrument halfway. power, the shape and the force of the electrode, the action
Since the uterus is an organ with very rich blood supply, time and the endometrial pretreatment, etc. Thus, the depth
uterine cavity is relatively narrow, and the uterine fundus and of the tissue thermal damage by coagulating electrode is
bilateral cornual portions have special anatomical and histo- neither as intuitive as the cutting electrode nor easy to
logical features, difficulties are brought about in the intra- evaluate.
uterine operations with cutting electrode. In addition, pure Electrocautery, a special form of coagulating current, is
cutting current cannot be used directly to coagulate the ves- mainly used clinically to stop bleeding of a larger area. This
sels. Therefore, clinically cutting current is commonly electrode uses the higher output voltage of coagulating cur-
blended with certain coagulating current, which can not only rent to produce spark discharge, at the same time, some of
ensure the effective cutting of the benign pathological the electrical energy is lost in the form of light. Therefore, it
changes in uterine cavity and endometrium, but also coagu- does not have the same depth of the tissue thermal effect as
late the blood vessels under the cutting site to achieve that of coagulating current. Electric spark coagulation is sel-
hemostasis. dom used in hysteroscopic operation.
48 H. Duan
5.3.3 Application of High Frequency 5.3.4 Application of High Frequent Bipolar

Vaporization in Hysteroscopic System in Hysteroscopic Electrosurgery
Electrosurgery
The major difference in monopolar and bipolar circuit sys-
It is not rare to destroy the endometrium and intrauterine tem in clinical treatment lies in that they pass through the
benign lesions in operative hysteroscopy by vaporization whole body or local tissues in the current circuit loop. The
principle. However, it is just beginning that vaporization biggest advantage of bipolar circuit is that it does not need
with high frequent electricity is applied in operative hyster- the return electrode plate, and the active electrode is mutu-
oscopy. Since 1980s, laser vaporization has mostly been ally adjacent to the return electrode, the current can only
applied in gynecological endoscopic operation to destroy the pass through the tissues between them, therefore, the elec-
lesions. In a comparative study of the removal of endome- trothermal effect is relatively limited. Bipolar circuit system
trium by laser vaporization and high frequency electricity, is applied quite a lot in laparoscopic surgery, with satisfac-
some scholars found that there was no difference in clinical tory outcomes and low occurrence of intraoperative and
effects between the laser group and the electrical cutting postoperative complications. The use of bipolar coagulation
group. However, due to the complexity of laser equipment, system in the treatment of uterine myoma and pelvic endo-
being expensive energy, and failure to obtain specimens for metriosis does not only produce less damage to the adjacent
histopathologic examination, it is gradually replaced by cut- tissues, but also gets better coagulating hemostatic effects,
ting and coagulating techniques with high frequency elec- thus rarely causing accidental electric damage to adjacent
tricity. Compared to cutting and coagulating electrodes, organs.
operation by vaporization is relatively simple, easy, and can Conventional bipolar circuit cannot produce the cutting
not only be used to remove larger neoplasm in uterine cavity, effect, but the birth of bipolar needle electrode enables endo-
but also avoid repeatedly interruption of surgery to take out scopic surgeons to perform effective cutting and coagulation
intrauterine tissue fragments. Furthermore, the electrical on pathological tissues in the bipolar circuit. The structure of
energy is cheap and the equipment is easy to use. Hence elec- a bipolar needle is shown in Fig. 5.9. The needle electrode is
tric vaporization can yet be regarded as a better method for located at the top of return electrode, and the active electrode
treatment. is 3 mm in length. The current acts on tissues through the
The working principle of high frequency electrical vapor- active electrode and completes the circle via return
ization is similar to that of laser, but the energy source is electrode.
different. Vaporization current is an undamped current with The animal experimental study by Isaacson et al. indi-
high power output. Its power setting is well over that of cut- cated that, at the same power output, the effects of both
ting and coagulating current. Vaporization electrode used in monopolar and bipolar systems on tissues were similar, and
hysteroscopic operation is a cylindrical electrode, which has there was no difference in thermal damage degrees through
equal spacing grooves. This structure can enlarge the contact their histological evaluations. Since the bipolar system must
areas between the electrode and the tissues, thus increasing work in an electrolyte solution, the complications like hypo-
the extent of the tissue damaged by the electrode. When the natremia may be avoided, which is caused by the use of non-
electrode is in operation, the strong output current may gen- ionic distending medium. At present, the hysteroscopic
erate higher current density inside the contacted tissue with bipolar vaporization system has been applied clinically.
the electrode. Its electrothermal effect can elevate the tem- When the active electrode is activated, a circuit is closed by
perature inside the tissues to vaporization temperature the electrolyte’s ions in distending medium, and the return
(≥100 °C). Glasser et al. recently reported that by using high electrode does not touch the tissues of human body, thus
frequency current to vaporize the endometrium, the depth of increasing the safety of operation, and harvesting a good
the tissue vaporization might reach 3–4 mm, and by clinical prospect of clinical application.
observation, the coagulating range of both the tissues under-
lying vaporization surface and the surrounding tissues is
1–3 mm. Therefore, a conclusion was drawn that the depth of
the tissue damage by vaporization was similar to that by
electric cutting. However, in the regions of the uterine cornua
or with larger vessels, coagulation with a rollerball electrode
is still used so as to avoid uterine perforation and intraopera-
tive hemorrhage. In addition, due to failure to obtain tissue
specimens during operation, only when combined with cut-
ting and coagulation electrodes, the vaporization can gain a Fig. 5.9 The structure of bipolar needle electrode. (a) Active electrode.
satisfactory outcome. (b) Return electrode
Suggested Reading 16. Onbargi LC, Hayden R, Valle RF, Del Priore G. Effects of power
and electrical current density variations in an in vitro endometrial
ablation model. Obstet Gynecol. 1993;82(6):912–8.
1. Duan H, Xia EL, Liang Y. Influence of the thermal effects of hys-
17. Pittrof R, Darwish DH, Shabib G. Nearfatal uterine perforation dur-
teroscopic endometrial ablation on tissues. Chin J Pract Gynecol
ing transcervical endometrial resection. Lancet. 1991;338:197–8.
Obstetr. 1999;34:479–81.
18. Serden SP, Brooks PG. Treatment of abnormal uterine bleeding
2. Daniell JF, Kurtz BR, Ke RW. Hysteroscopic endometrial ablation
with the gynecologic resectoscope. J Reprod Med. 1991;36:697–9.
using the rollerball electrode. Obstet Gynecol. 1992;80:329–32.
19. Soderstrom RM. Electricity inside the uterus. Clin Obstet Gynecol.
3. Glasser MH. Endometrial ablation and hysteroscopic myomectomy
1992;35:262–9.
by electrosurgical vaporization. J Am Assoc Gynecol Laparosc.
20. Townsend DE, Richart RM, Paskowitz RA, Woolfork RE.
1997;4:369–74.
“Rollerball” coagulation of the endometrium. Obstet Gynecol.
4. Goldfarb HA. Bipolar laparoscopic needles for myomacoagulation.
1990;76(2):310–3.
J Am Assoc Gynecol Laparosc. 1995;2:175–9.
21. Tucker RD, Kramolowsky EV, Platz CE. In vivo effect of five
5. Holm-Nielsen P, Nyland MH, Istre O, Maigaard S, Forman
french bipolar and monopolar electrosurgical probes on the porcine
A. Acute tissue effects during transcervical endometrial resection.
bladder. J Urol Res. 1990;18:291–4.
Gynecol Obstet Invest. 1993;36(2):119–23.
22. Valle RF. Hysteroscopic treatment of partial and complete uterine
6. Indman P, Brown W. Uterine surface changes caused by electrosur-
septum. Int J Fertil Menopausal Stud. 1996;41:310–5.
gical endometrial coagulation. J Reprod Med. 1992;37:667–70.
23. Wortman M, Daggett A. Hysteroscopic endomyometrial resection:
7. Indman PD, Soderstrom RM. Depth of endometrial coagulation
a new technique for the treatment of menorrhagia. Obstet Gynecol.
with the urologic Resectoscope. J Reprod Med. 1990;35:633–5.
1994;83:295–8.
8. Kaplan SA, Te AE. Transurethral electrovaporization of the pros-
24. Gaillard MC, De Grandi P. Endometrectomy: comparison of
tate. A novel method for treating men with benign prostatic hyper-
Nd-Yag laser and resectoscope. Gynakol Geburtshilfliche Rundsch.
plasia. Urology. 1995;45:566–72.
1994;34(1):7–16. Germanica.
9. Loffer FD. Removal of large symptomatic intrauterine growths by
25. Gong Z, Zhan R. Pathological tissue specimen making and stain-
the hysteroscopic resectoscope. Obstet Gynecol. 1990;76:836–40.
ing technique. Shang Hai: Shanghai Science & Technology Press;
10. Isaacson K, Nardella P. Development and use of a bipolar resecto-
1994. p. 343–53.
scope in endometrial electrosurgery. J Am Assoc Gynecol Laparosc.
26. Qibo L. Practical pathological special staining and histochemical
1997;4:385–91.
technique. Guang Zhou: Guangdong Higher Education Publish
11. Duan H, Xia EL. Application of HF electricity in hysteroscopic
House; 1989. p. 1–32.
surgery and its development. China J Endoscopy. 2000;6:18–20.
27. Liu F. Principle, structure and maintenance of medical electronic
12. Luciano AA, Soderstrom RM, Martin DC. Essential principles
instruments, vol. 14–25. Beijing: China Medical Science and
of electrosurgery in operative laparoscopy. J Am Assoc Gynecol
Technology Press; 1997. p. 339–49.
Laparosc. 1994;1:189–95.
28. Nan D. Principles and maintenance of medical instruments. Shang
13. Luciano AA. Power sources. Obstet Gynecol Clin North Am.
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1995;22:423–43.
29. Brill AI. What is the role of hysteroscopy in the management of
14. Neuwirth RS, Amin HK. Excision of submucous fibroids with hys-
abnormal uterine bleeding? Clin Obstet Gynecol. 1995;38:319–45.
teroscopic control. Am J Obstet Gynecol. 1976;126:95–9.
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Gynecol Clin North Am. 1995;22:541–58.
Distention Medium in Hysteroscopy
6
Limin Feng
Hysteroscopic examination and operation are effective meth- During the hysteroscopic surgery, on the one hand, the
ods for the diagnosis and treatment of the dysfunctional uter- uterine vessels are cut off when the endometrium and myo-
ine bleeding and other benign lesions in the uterine cavity. metrium are resected, so the distention medium with a cer-
The sufficient distention and clear visualization of the uter- tain pressure flows into the body through the open vessel. On
ine cavity is one of the most important factors for examina- the other hand, the distention medium can flow into the
tion and treatment, so an appropriate distention medium is abdominal cavity via the fallopian tubes and then is absorbed
necessary for either diagnostic or operative hysteroscopy. by the peritoneum, but its absorptive ability seems to be quite
The most commonly used distension media include gaseous little. In many countries, a hysteroscopic surgery is always
medium (CO2), low viscosity liquids (such as glycine, glu- monitored by laparoscopy. Either laparoscopic suction of the
cose, mannitol or sorbitol, and normal saline), and high vis- distending fluid flowing into the abdominal cavity via the
cosity liquids (such as dextran-70). However, due to the fallopian tubes at the end of hysteroscopic surgery or intra-
serious allergic reactions, the use of high viscosity liquids operative ligation of both fallopian tubes laparoscopically
has already been prohibited. The procedures of hystero- cannot prevent the complications caused by the absorption of
scopic resection are performed under the continuous irrigat- the distention medium, unless the hysteroscopy is compli-
ing of distention media. It is done after the resectoscope cated by the perforation of the uterus and then a large amount
being inserted into the uterine cavity through the cervical of distention medium flow into the abdominal cavity, which
canal, with both the whole endometrial layer and 2–3 mm are then absorbed by the peritoneum and lead to a change in
myometrial layer underlying the endometrium being resected electrolytes. However, Istre held that an apparent absorption
so as to achieve the aim that the endometrium cannot regen- by the peritoneum might occur within 4 h after operation.
erate. This operation is quite similar to transurethral resec- The hysteroscopic surgery can also be monitored with ultra-
tion of the prostate (TURP) in that a large amount of liquid sonography, so it can be used to examine the distention
distension medium (irrigating fluid) can be absorbed via the medium during the operation, which flows into the abdomi-
intraoperative open veins into the circulation. Furthermore, nal cavity through the opening tubes and gathers in the pos-
the uterus is different from the bladder in that the uterus is an terior fornix and then disappears. With years of clinical
organ with certain thickness and a hidden cavity which needs observation, gynecologists of the Hysteroscopy Center in Fu
a very high distending pressure. What’s more, there is much Xing Hospital, Capital Medical University believed that the
richer blood supply in the uterine wall than in the bladder amount absorbed via the abdominal cavity is quite little.
wall, so there will be more absorption of distention medium The damage caused by the absorption of distention
during hysteroscopic surgery than that during TURP, result- medium firstly raised concern in the 1950s when Creevy
ing in the syndrome of transurethral resection of the prostate reported the first hemolytic reaction resulting from the
(TURP syndrome). This syndrome leads to the occurrence of absorption of the sterile distilled water which was used as
hyponatremia, and if not corrected immediately, it could fur- irrigating fluid in a patient who had TURP. To prevent this
ther cause the damage to cardiovascular system, serious neu- complication, Creevy proposed the idea of using a “non-
rologic and mental abnormalities, and even death, which are toxic and non-hemolytic distention medium.” The other fea-
serious complications of endoscopic electro-resection. tures of an ideal distention medium are isotonicity and high
visualization, and that the increase in plasma and extracel-
lular fluid caused by the absorption of distention medium is
L. Feng (*) temporary and minimum. In addition, a distention medium
Department of Obstetrics and Gynecology, Beijing Tiantan
should not crystallize on the surface of surgical instruments.
Hospital, Capital Medical University, Beijing, China

52 L. Feng
6.1 CO2 Gas Insufflation A number of cases proved that CO2 insufflation could
make a clear visualization, with the hysteroscope being
CO2 is a colorless gas. It is handy, and its safety can be guar- directly placed into the uterine cavity through the cervical
anteed if there is an appropriate gas insufflating machine. canal without the requirement of dilating the cervical canal,
Linderman and Mohr reported that there was no complica- and CO2 was insufflated continuously by irrigating through
tion happened in more than 1200 cases using CO2 gas insuf- the inflow channel of the hysteroscope from the insufflator.
flation for hysteroscopy. The gas insufflation machine can The gas leakage could be prevented by using an appropriate
perfuse gas continuously. After pre-setting the pressure, the cervical suction cup or holding forceps.
flow rate can be automatically adjusted to an optimal state. If Performing the diagnostic hysteroscopy carefully during
the pressure increases, the flow rate could be automatically the luteal phase can improve the sharpness of the vision,
reduced so as to prevent the complications induced by exces- decrease the bleeding and reduce the obstruction of mucus to
sive pressure. The maximum flow rate and pressure in the the vision. Due to the lower refractive index of CO2, it can
uterine cavity of CO2 gas insufflation are 100 mL/min and make a clear vision, but its magnification is lower than that in
200 mmHg respectively, while the most suitable flow rates the liquid distending media. Moreover, the CO2 bubbles can
range between 40 and 60 mL/min, and the most suitable be mixed with the blood, which may develop into the foam
pressures range between 40 and 80 mmHg. and affect the vision. In addition, it can make the endometrial
The laparoscopic insufflators must never be connected to debris float in the uterine cavity which leads to the difficulty
a hysteroscope, as they supply the abdominal pressure by L/ of sampling. For multipara and patients who have had cervi-
min, which is far higher than the flow rate of uterine disten- cal conization, gas leakage can affect the surgeon’s observa-
tion (mL/min) for hysteroscopy. The complications of CO2 tion so other distending media are strongly suggested.
uterine distention—tubal rupture, hydrosalpinx and medias-
tinal rupture—are mainly caused by improper use of gas
insufflation machine. Cardiac arrhythmia and cardiac arrest 6.2 High Viscosity Distention Medium:
are also reported, which may be caused by too much absorp- Hyskon
tion of CO2. However, animal experiment models confirmed
a wide range of its safety. A large volume of CO2 entering the Hyskon is a mixed solution of 32% dextran-70 in 10% glu-
abdominal aorta almost did not cause cardiovascular compli- cose, and is produced by the fermentation of bacterial poly-
cations, but the endoscopic surgeons should remember to use saccharides. The average molecular weight of dextran in
the minimum flow rate so as to achieve the optimal effect of Hyskon is 70,000, which belongs to a middle-molecular-
insufflation. weight dextran and is a colloidal solution. The dextran devel-
According to a survey conducted by the American oped in 1940s was firstly used in blood volume expansion,
Association of Gynecologic Laparoscopists (AAGL) in which is to expand the blood volume by the absorption of the
1991, the incidence rate of CO2 embolism during hystero- extravascular water under its colloid osmotic pressure. As a
scopic surgery was 0.1/1000. Although these cases were not distending medium, Hyskon has the advantage of not mixing
described in detail, it was clear that both the embolism and with blood. The metabolism of dextran is determined by its
death occurred in Nd: YAG laser operations cooled by CO2. molecular weight. The low-molecular-weight dextran
The flow rate of CO2 when it is used for cooling the tip of (<50,000u) can be filtered by the kidney so only minute
laser is comparable to that of gas insufflators, which is 500– quantity may be absorbed; the middle-molecular dextran
1000 mL/min. The fact that the CO2 embolism may cause should be gradually degraded into low-molecular-weight
serious cardiovascular damage and death prompted the FDA dextran and then be discharged through the kidney; and the
to prohibit strictly the use of CO2-cooled laser in high-molecular-weight dextran can be metabolized by the
hysteroscopy. reticuloendothelial system.
CO2 is an ideal distention medium for diagnostic hyster- It was reported in recent years that the absorption of
oscopy, which can be done with CO2 distention of the uterine Hyskon into blood vessels might cause anaphylactic shock
cavity under local anesthesia of the patient. Jong et al. and non-cardiogenic edema, and even there was a reported
reported that hysteroscopies were performed in 152 outpa- case of instant anaphylactic shock when Hyskon was used.
tients under cervical block anesthesia with 1% lidocaine. According to the immunology, allergic reactions may be
Although some patients were extremely nervous, such as caused by the second encounter with the allergen after the
nulliparous women and women who had undergone cervical antibody has already been produced by the first contact with
conization, most of them believed that this procedure was antigen. The allergen of Hyskon may be sugar, and cross-
durable, and 90% thought that the degree of discomfort was reaction may occur with the bacterial antigens, such as strep-
lower than that of dysmenorrhea. tococcus, pneumococcus, and salmonella. Although the
6 Distention Medium in Hysteroscopy 53
incidence of such kind of anaphylactic shock is quite low, coma, collapse, and even death. The use of low viscosity dis-
being only 1/10,000, Ahmed et al. reported that three such tending fluid in hysteroscopic surgery, including glycine,
cases occurred in their hospital during only half a year. The sugar alcohol such as mannitol and sorbitol, is also prone to
amount of Hyskon administered in these three cases was all the occurrence of TURP syndrome, and its incidence is
<100 mL, and skin test was negative in the postoperative reported at a maximum of 50% and a minimum of 5%.
dextran allergic reactions. Moreover, the risk of anaphylactic
reaction in allergic patients did not increase compared with
that in nonallergic people. As a result, the occurrence of 6.3.1 Research on Complications Induced by
allergic reactions cannot be predicted when dextran is in use. Glycine Absorption
Most reports of pulmonary edema caused by absorption of
Hyskon suggested that it was related to the effect of dextran Glycine (CH2·NH2·COOH) is a water-soluble small amino
in pulmonary vessels, and such direct toxicity reaction also acid with the commonly used concentration of 1.5%. And it
occurred when other molecular weight dextrans were in use. is hypotonic non-electrolyte solution with the osmotic pres-
The most possible cause of pulmonary edema secondary sure of 200 mOsm/L. The water intoxication caused by its
to absorption of Hyskon is the increased blood volume. absorption via the blood vessels appears as hypervolemia
Clinically, dextran has been used as a plasma substitute for and hyponatremia. The incidence of these complications is
the plasma volume expansion, but high-molecular-weight up to 2% in TURP procedures.
dextran is prohibited in expanding the blood volume. During hysteroscopic surgery, when larger vessels in uter-
Because dextran has the property of slow metabolism, it can ine cavity are cut off, glycine, a distention medium with cer-
significantly increase plasma colloid osmotic pressure, tain distending pressure, can be absorbed quickly via the
which can promote a further increase in blood volume, lead- open veins. When glycine enters the circulatory system, the
ing to the movement of fluid and electrolytes. Each gram of serum sodium levels are declined. Under normal circum-
dextran −70 can carry 20–27 mL of water into the blood stances, sodium and other positive ions play a decisive role
circulation, so the absorption of only 100 mL of Hyskon can in plasma osmotic pressure. Rapid reduction in the serum
lead to the expansion of blood volume by 860 mL. Therefore, sodium often leads to the prompt reduction in plasma osmotic
the blood expanding volume can be ten times more than the pressure, but the initial absorption of the glycine molecules
amount of Hyskon absorption (e.g. When 100 mL of Hyskon contributes to the maintenance of plasma osmotic pressure.
is absorbed into the blood, the blood volume will be However, glycine cannot remain in the blood vessels for
expanded by 100 mL of Hyskon and 860 mL of fluid mov- long, and the half-life of its molecules after being absorbed
ing from the interstitial space into vessels). However, in the into vessels is 85 min. The longer the operative time is and
published literatures, it was not described in details about the wider the excised tissues are, the more the glycine
the amount of Hyskon absorption. Therefore there will be absorption will be, which eventually leads to an increase in
fold increases in the blood volume when Hyskon is absorbed, free water. If this free water cannot be metabolized quickly,
with 350 mL of Hyskon absorption leading to 3.5 L of vol- hypotonic hyponatremia will occur. Because of the adverse
ume expansion. effect of the antidiuretic hormone in hysteroscopic surgery,
Unlike the low viscosity distending fluid, Hyskon does not diuretics are rarely used in surgical procedures. In addition,
cause water intoxication, and more specifically, fluid imbal- because of the effect of the female hormone on sodium-
ance is secondary to the absorption of colloid osmolytes (dex- potassium adenosine triphosphate anhydride, female patients
tran) whose half-life may last for several days. Excessive are more susceptible to hyponatremia, for example, proges-
absorption of dextran −70 may lead to the movement of body terone can inhibit this kind of Na + –K + ATPase in several
fluids and electrolytes into vessels, so dextran causes fluid different tissues.
overload by changing the colloid osmotic pressure. The dangers of hyponatremia lie in inevitable brain dam-
age, because the water molecules can pass freely through the
cell membrane, and quickly establish intravascular, intracel-
6.3 Low Viscosity Distention Medium lular and extracellular equilibriums of osmotic pressure.
Inside and outside the cells, it is easy for water to move from
Bradycardia and hypertension may occur in patients with that being hypotonic (high water content) to that being hyper-
TURP syndrome, followed by hypotension, nausea, vomit- tonic (low water content), so that the equilibrium of osmotic
ing, headache, impaired vision, excitement, mental disor- pressure is maintained both inside and outside the cells. Water
ders, and lethargy, all of which resulting from the dilutional molecules can also pass across the brain barrier freely, and the
hyponatremia and a reduction in plasma osmotic pressure. If animal experiments and human observations both confirmed
not diagnosed and treated in time, they can induce seizures, that hyponatremia most easily hurt the brain barrier. Therefore,
54 L. Feng
a rapid increase of free water in vessels will lead to a drop in ucts; a temporary reduction in oxyhemoglobin saturation;
osmotic pressure and the transfer of water into the brain cells. and hypercapnia. However, the reasons were not clear.
When suffering from the cerebral edema, brain tissues can be Glycine had been considered as a safe and atoxic distention
damaged due to the narrow space of the cranial cavity. medium for many years, but the recent literature studies held
Increased intracranial pressure can reduce the blood flow a negative attitude.
velocity, resulting in hypoxia. An increase in the intracranial
pressure by 5% can lead to brain herniation, while an increase
by 10% can be life-threatening. 6.3.2 Research on the Complications Induced
Hyponatremia may be an independent factor for TURP by Absorption of Sorbitol and Mannitol
syndrome. Na+ can affect the metabolism of cardiac smooth
muscles and skeletal muscles, the release of nerve impulses, Sorbitol and mannitol can also be used as irrigating fluid in
cell membrane potential and the permeability of cell mem- hysteroscopic surgery. Cytal, the most commonly used solu-
brane. Animal model experiments have confirmed the dam- tion, includes 2.7% sorbitol and 0.54% mannitol, and the use
age of hyponatremia to the central nervous system. In this of higher concentrations has also been reported. However,
study, when the experimental animals got severe hyponatre- high concentrations of sorbitol and mannitol can be melted
mia under the normal osmotic pressure, they would always into caramel under high temperature when doing electric cut-
been in states of lethargy, twitching, or coma. Thus the ting, so it is rarely used clinically. Sorbitol and mannitol are
authors believed that hyponatremia rather than low osmotic six carbon isomers. Sorbitol is metabolized into fructose and
pressure was the main factor for its onset. glucose in the liver. Mannitol itself is inactive, only 6–10%
In addition to the low osmotic pressure and hyponatremia, can be absorbed and metabolized, and the rests are filtered
another complications induced by glycine are caused by the through the kidney and excreted into the urine as prototype.
products of glycine metabolism. The oxidative deamination Therefore, mannitol can produce the effect of osmotic diure-
of glycine is catalyzed by methyltransferase in the liver, sis, which theoretically helps to improve the symptoms of
forming glyoxylate and ammonia in the kidney. Then the fluid overload and secondary hyponatremia. However, the
glyoxylate is further metabolized into oxalic acid, forming half-life of mannitol in plasma is 1.5 h in patients with normal
oxalic acid crystals in the urine. There were many reports on renal function, which is unhelpful to fluid equilibrium and
the use of glycine causing hyperammonemic encephalopathy recovery of cardiac function. The half-life can be further
in urologic surgery. If hyponatremia and low osmotic pres- extended due to the blockage of excretion if patients have kid-
sure cannot account for patients’ symptoms of central ner- ney disease. The isotonic mannitol 5% has ever been used as
vous system disorders, possibility ammonia poisoning irrigating fluid for hysteroscopic surgery in the hysteroscopic
should be considered. The incidence of hyperammonemia in center of Fuxing Hospital, Capital Medical University. It was
patients with combined preoperative liver disease does not found that the mannitol had the advantage of having the effect
increase. In patients with severe ammonia poisoning, l- of diuresis when it enters the circulation, which might reduce
arginine can be used to stimulate the ammonia metabolites the side effects caused by fluid overload, and it has the draw-
moving into the urea cycle. backs of both forming a layer of crystal on all contacted sur-
The absorption of glycine may also affect the visual acu- faces after it is dried and possibly leading to postoperative
ity. In a prospective study of 18 patients who underwent hypotension after it produces diuresis and dehydration.
TURP, a transient decrease in visual acuity occurred in four
patients. It might be caused by the secondary impact of gly-
cine on neurotransmitters, with the formation of the inhibi- 6.3.3 Research on the Safety of 5% Glucose
tors of the neurotransmitters in the retinal ganglion and as Irrigating Fluid
horizontal cells. On the contrary, the blood ammonia levels
in the asymptomatic group are significantly higher, which After years of research, many scholars have believed that an
might be due to the fast metabolism of glycine in asymptom- ideal distention medium is supposed to be sterile, non-toxic,
atic group. Some scholars have confirmed the significant and able to maintain the osmotic pressure of an organism; it
individual differences in the speed that amino acid is pro- should have good transparency and not mix with blood, and
duced through the metabolism of glycine in human body. could ensure a clear operational view; it is non-conductive,
Some other scholars reported that glycine, as uterine dis- low viscosity, easy to prepare, and relatively inexpensive;
tention medium, could cause obvious alterations in the func- and its metabolites are very few and harmless. In recent
tion of blood coagulation, which mainly included the years, the latest progress in hysteroscopic electro-resection
reductions of the platelets, fibrinogen, and the erythrocyte with continuous irrigation is to use low viscosity distention
binding rate; the extension in partial thromboplastin time and media. However, according to the criteria above, those
prothrombin time; the presence of fibrin degradation prod- commonly used distention media abroad are not very satis-
factory. Since 1990, 5% glucose has been used as distention patients do not have any complaints of discomfort according
medium in the Hysteroscopy Center of Fuxing Hospital, to clinical observations. Animal experiments have also con-
Capital Medical University and found: firmed that there is significant increase in blood glucose level
in 5% glucose group, while there is no increase in blood glu-
1. Serum sodium level decreased gradually to the lowest cose level in 5% mannitol group, but a high mortality.
point 1 h after operation and began to recover 4 h later. Therefore, high blood glucose is not the cause of death in
All changes were within normal range, without any clini- experimental animals. If a transient increase in blood glu-
cal symptoms of hyponatremia. cose could lead to a transient increase in plasma osmolality
2. Serum potassium level decreased gradually to the lowest and water movement from the intracellular to the extracel-
point 1 h after operation, began to recover 4 h later and lular space, it would be the theoretical basis for some schol-
resumed normal 24 h later. All changes were within nor- ars’ belief that the glucose as irrigating fluid may aggravate
mal range, without any change in hypokalemia. hyponatremia. However, we think this just partially offsets
3. The level of blood chloride decreased gradually to the the extracellular hypotonicity and blocks some tendency of
lowest point 1 h after operation and began to recover to water movement from the extracellular space to the intracel-
normal from 4 h after operation. lular, so a transient increase in blood glucose will not aggra-
4. Blood glucose levels significantly increased to the high- vate the reaction of hyponatremia, but reduce the cell
est point 1 h after operation and returned to preoperative swelling and decrease the onset of hyponatremia. Of course,
levels 4 h after operation. the use of 5% glucose as irrigating fluid for hysteroscopic
5. The plasma osmotic pressure decreased gradually to the surgery is not recommended in patients with diabetes and the
lowest point 1 h after operation and began to recover 4 h elderly ones due to their hypoinsulinism.
later. Some studies suggested that 5% glucose was non-
electrolyte solution with the osmotic pressure of 278 mOsm/L
The focus of whether 5% glucose can be applied in the which was close to the tension of the blood plasma (280–
irrigation for hysteroscopy lies in the influence of the changes 320 mOsm/L), so it was known as isotonic solution. After
in blood glucose level on the human body. We believe that being absorbed into the blood, it does not affect the tension
there is significant increase in blood glucose level after sur- in the red blood cells, so the red blood cells will neither swell
gery, which is highly correlated with the absorption of the nor shrink, but maintain its original integrity. However, glu-
irrigating fluid. If the patients did not have diabetes, the tran- cose in the body is soon oxidized to CO2 and H2O, and sup-
sient hyperglycemia would not produce significant physio- plies the energy at the same time, or it is stored in liver cells
logical changes. We found that the level of blood glucose in the forms of glycogen, both of which leading to the loss of
began to increase at the end of the operation, and peaked 1 h the original tension. Therefore, 5% glucose solution is iso-
after operation, and returned to preoperative levels 4 h after tonic solution apparently, but it can be used as tension-free
operation, which recovered faster than the levels of potas- solution due to its shortly-lasting tension in the body. Glucose
sium, sodium, and chlorine. Some scholars doubted that returns to preoperative levels 4 h after operation, so the high
hyperglycemia would cause hypertonic and dehydration, and metabolic rate would not cause the pathophysiological
even aggravate hyponatremia, leading to the symptoms of changes in the body.
central nervous system disorders. However, because of the Two phase contrast ultrasonography is applied in the
great molecular weight of glucose, its osmotic pressure is monitoring of the whole surgical process of hysteroscopy.
limited. If the blood glucose increases by 10 mmol/L That is, the bladder is filled and the distention medium is
(180 mg%), the osmotic pressure will increase by injected into the uterine cavity, and strong echogenic band of
10 mOsm/L. If the blood glucose increases by 20 mmol/L light is formed under the high-frequency electric effect on
(360 mg%), the osmotic pressure will increase by the inner wall of the uterus. This unique change in the sono-
20 mOsm/L. In our study, the maximum level of blood glu- gram is an effective indication for ultrasonography monitor-
cose is 469 mEq/L, and in theory, the osmotic pressure ing of intrauterine electro-resection. Meanwhile, it is found
should increase by 26 mOsm/L. Animal experiments have in some patients that the irrigating fluids infiltrating into the
confirmed that if the plasma osmolality is >350 mOsm/L, the muscle wall present cloudy strong echo, forming a special
animals will develop anxiety and irritability; if it is within ultrasonic image (Fig. 6.1). A statistical analysis has been
375–400 mOsm/L, they will have nystagmus, ataxia, and made for this phenomenon. According to other scholars’
limb shaking; if it is >400 mOsm/L, they will have startle research, adverse effects may occur when absorption of dis-
and develop tonic limb spasms; and if >435 mOsm/L, no tention medium is >900 mL, so we also took this as the stan-
animals will survive. Thus even if the plasma osmolality dard. The result showed that in patients with infiltration of
increases by 26 mOsm/L due to hyperglycemia, it does not distention medium revealed by ultrasonography, there was a
produce significant pathophysiological changes and the significant increase in the absorption of the distention
56 L. Feng
irrigating fluid into the blood circulation. Though very rare,

it may lead to a death rate of 15–40% once occurring. Early
in 1946, Greevy et al. reported that, during a transurethral
electro-resection, the distilled water was used as irrigating
fluid, which entered blood circulation through the open
veins caused by resection and increased the blood volume
rapidly in a short time, leading to the destruction of large
numbers of erythrocytes and then production of great quan-
tities of hemoglobin, which finally resulted in impaired
renal function. Afterwards, many scholars conducted the
experimental studies by injection of the hemoglobin into
the blood of animals, and the results showed that a large
amount of hemoglobin in blood circulation did not cause
impaired renal function. And when hemoglobin 50 g was
injected into blood of human body at one time, it would be
completely discharged out of the body after 30 h, causing
no damage to the renal function. In 1955, Hagstrom firstly
named transurethral resection of the prostate syndrome
(TURP syndrome), described the typical clinical symp-
toms, and pointed out clearly that the true cause of the syn-
drome was the sudden decrease in plasma sodium. After
more than 20 years of clinical practice and research, the
mechanism of TURP syndrome has been clearly under-
stood theoretically. Among them, Guy et al. conducted
quite a lot of animal experiments and clinical observations
and confirmed that the cause of TURP syndrome when gly-
Fig. 6.1 The irrigating fluid infiltrates into the muscle wall, presenting cine was used as distention medium was neither hyperam-
cloudy strong echo under ultrasonography
monemia nor low osmotic pressure hyperlipidemia, but
hyponatremia. The clinical manifestations of TURP syn-
medium. It was thought that such patients may have adeno- drome are bradycardia and hypertension secondary to
myosis. The formation of strong echo when irrigating fluid hyponatremia, followed by hypotension, nausea, vomiting,
infiltrates into the muscle wall may result from the direct headache, impaired vision, excitement, mental disorders,
extension of the basal endometrium into the myometrium and lethargy. If not cured immediately, it can result in cere-
and the reactive hyperplasia of uterine muscle fibers. If the bral edema, herniation, leading to seizures, coma, collapse,
glandular tubes in the muscle wall communicate with the and even death. All these symptoms are caused by dilu-
uterine cavity, under ultrasonography, the irrigating fluid can tional hyponatremia and hypervolemia. And it is also sug-
be seen infiltrating into the focal areas of the uterine wall, gested that the low osmotic pressure is also one of the
and the bubbles can be detected accumulating in the cavity causes of this syndrome.
below the anterior wall, thus forming a special ultrasonic To verify that a transient hyperglycemia does not aggra-
image. This is also another way of distention medium absorp- vate hyponatremia, the researchers in the Hysteroscopy
tion, which cannot be neglected and needs to be further stud- Center of Fuxing Hospital, Capital Medical University
ied and confirmed. designed an animal experiment, the results were as follows:
1. There was a drop in plasma sodium in Wista rats of 5%

6.4 Etiology and Clinical Presentation glucose group, 5% mannitol group and the balanced solu-
of TURP Syndrome tion group, and the most significant drop was in mannitol
group.
6.4.1 Etiology of TURP Syndrome 2. There was an increase in plasma potassium levels in all
three groups, and the most significant increase was in
TURP syndrome has been the most serious complication of mannitol group.
transurethral electro-resections. It refers to a series of 3. There was an increase in plasma chloride levels in three
symptoms in the whole body caused by hypervolemia and groups, and the most significant increase was in mannitol
hyponatremia, which results from excessive absorption of group.
4. There was an increase of varying degrees in the blood Surgical treatment of intrauterine disorders has become a
glucose level in three groups, and the most significant trend in gynecological surgery, which has greatly decreased
increase was in glucose group. the administration of hysterectomy in many developed coun-
5. There was a drop in plasma osmotic pressure in three tries. In the past, 20% of the patients with dysfunctional uter-
groups, and the most significant drop was in mannitol ine bleeding (DUB) needed to undergo hysterectomy, but
group. hysteroscopic surgery can cure or effectively reduce the
6. Status of animal survival: 2 died within 1 h and 4 died irregular vaginal bleeding in 80–90% of patients with
within 2 h in the group of 5% mannitol, 1 died in the DUB. In addition, treatment of uterine septum, submucous
group of 5% glucose, and 14 died in the group of manni- myoma, and intramural myoma can achieve therapeutic pur-
tol within 24 h. poses without laparotomy so as to avoid the short-term and
long-term complications caused by open surgery. The hys-
In recent years, the use of low viscosity uterine distending teroscopic surgery has fewer complications, shorter opera-
medium during hysteroscopy with continuous irrigating has tive time, and shorter length of hospital stay and rapid
been more and more advocated. The most frequently used recovery after operation. Since a high viscosity uterine dis-
media abroad are 1.5% glycine, Cytal solution and 5% man- tending medium may cause serious complications such as
nitol. There is no 1.5% glycine and Cytal solution available allergic-like reaction, non-cardiogenic edema, and coagula-
in our country presently, so 5% mannitol and 5% glucose are tion disorders, nowadays people tend to use low viscosity
used in our study. uterine distending media which have fewer complications.
As to the research on low viscosity fluid, it is found that The most frequently used distending medium abroad is 1.5%
1.5% glycine cannot only easily lead to TURP syndrome, but glycine, but the occurrence of hyponatremia has increasingly
also cause an increase in blood ammonia levels by its metab- caught people’s attention. Recently, there have also been
olites, resulting in a series of neurological and psychiatric continuous reports on hyperammonemia or death caused by
symptoms and a transient decrease in visual acuity, which great amounts of absorption of 1.5% glycine.
has been increasingly concerned by the hysteroscopists. The As to the application of 5% glucose as irrigating fluid in
deep studies on the application of 5% mannitol as the irrigat- hysteroscopic electro-resection, there have been 13 cases
ing fluid in the hysteroscopic resection are obviously inferior reported by Lin about hysteroscopic resection of submucous
to that of 1.5% glycine. Although complications of water myoma, but without any discussion on its safety. Sandra
intoxication and hyponatremia induced by mannitol are sim- et al. performed hysteroscopic surgery using 5% glucose as
ilar to those of 1.5% glycine, only 6–10% of mannitol are the distention medium on four patients experimentally in the
absorbed and metabolized due to its inactive ingredient, and year of 1989, and the results discovered that all four patients
the rest is filtered by kidney and excreted into the urine as developed hyperglycemia, with 2 of whom associated with
prototype. Therefore, mannitol can produce an effect of serious hyponatremia. Therefore, it was believed that high
osmotic diuresis, and theoretically helps to reduce the dan- blood glucose could aggravate hyponatremia. However, after
gers of the fluid overload and secondary hyponatremia. Thus analyzing Sandra’s study, we believe that the distention pres-
Arieff believed that the isotonic mannitol was the most suit- sure up to 150–250 mmHg they used was the inevitable rea-
able for irrigating during electro-resection because it is non- son for the aggravation of hyponatremia in patients.
conductive with only a little amount being metabolized in the According to many years’ research on hysteroscopic electro-
body and will not cause a change in low osmotic pressure. resection, some scholars thought that the best distention
However, the animal experiment confirmed the fact that the pressure was 60 mmHg. However, Quinones declared that
severity of hyponatremia, hypokalemia, low chlorine, and the bilateral tubal ostia could not be seen until the intrauter-
low osmotic pressure caused by the absorption of 5% man- ine pressure was raised to 100–110 mmHg. However, it is
nitol was significantly higher than that of 5% glucose group. generally acknowledged by most scholars that the intrauter-
With respect to the recovery of animal behavior and survival ine pressure should not be higher than 100 mmHg, and even
rate, there was also significant difference between two some scholars thought that there would be rare complica-
groups. In addition, these experimental results showed that tions if the distention pressure was <100 mmHg.
there was an obvious increase in blood glucose only in the We used 5% glucose as irrigating fluid in various hystero-
group of 5% glucose, which confirmed that the increase in scopic intrauterine operations, and found no TURP syn-
blood glucose would not increase the reaction of hyponatre- drome occurred, even in women complicated with renal
mia and mortality of animals. Therefore, the researchers failure, kidney transplantation, heart failure, cardiac valve
believed that application of 5% glucose in hysteroscopic replacement surgery, blood diseases, and so on. Amratage
electro-resection was superior to 5% mannitol with regard to held that the procedure of hysteroscopic electro-resection
biochemical changes, the economic burden, the convenience should be stopped if the absorption of irrigating fluid was
of preparation, or the confirmation of clinical observations. more than 1000 mL. However, in our study, the largest
58 L. Feng
v olume of irrigating fluid absorption was 1520 mL, and no rate, elevated CVP, heart failure, and hemolysis. Then, there
hyponatremia was found to occur by either clinical observa- may be more serious dyspnea, metabolic acidosis induced by
tion or biochemical tests. With the measurements of the excessive lactic acids produced by tissues; and shock due to
plasma electrolytes, blood glucose and plasma osmotic pres- worsened heart failures. Ventricular arrhythmias, mental
sure and a contrast study conducted with 5% mannitol, it was confusion, lethargy, and death may follow in severe cases.
further confirmed that 5% glucose used as irrigating fluid in
intrauterine surgery was safe and economical, and was wor-
thy of popularization. Of course, in order to avoid excessive 6.5 Treatment of TURP Syndrome
fluid absorption, the operative time should be shortened as
much as possible and the irrigating pressure should be con- The treatment of TURP syndrome includes monitoring of the
trolled. If the infiltration of fluid into the uterine muscle wall vital signs, management of disorders such as hyponatremia,
was detected during operation, the absorption of irrigating heart failure, pulmonary edema, and cerebral edema, and
fluid and the electrolyte balance should be closely moni- correction of electrolyte disturbance and acid-base
tored. In addition, close observation after operation should imbalance.
be done so as to avoid the occurrence of electrolyte distur-
bances post-operation.
6.5.1 Treatment of Hyponatremia
6.4.2 Clinical Presentation of TURP Syndrome Treatment of hyponatremia is aimed at potent diuresis and
sodium replacement.
The pathophysiological changes of TURP syndrome are The precautions in the use of potent diuretics are: pay
dilutional hyponatremia and acute hypervolemia, with the attention to its dosage, which can be decided through mea-
clinical presentations mainly appearing as increased heart surement of the hemoglobin content and relative density of
rate and increased blood pressure; lowered blood pressure, urine, and through measurement of the central venous pres-
nausea, vomiting, headache, blurred vision, restlessness; sure as well. And attention should also be paid to serum elec-
dyspnea, pulmonary edema; arrhythmia, decreased heart trolytes for prevention of hypokalemia.
6.5.1.1 Calculation of the Serum Sodium Deficit
Sodium replacement required = ( normal sodium − Patient ’s sodium ) × 522% × kg body weight
52% refers to the ratio of person’s body fluids to the total for half an hour, which includes consciousness, mental
weight. status, blood pressure, heart and lung function, and serum
sodium concentration. Those are basis to determine the
6.5.1.2 Key Points in the Replacement of Sodium replacement amount of the rest deficient, when hyper-
1. Rapid and high concentrations of intravenous sodium tonic saline is always used.
replacement should be avoided. 6. Sodium replacement can just maintain serum sodium
2. During the acute phase of hyponatremia, the replacement concentration at 130 mEq/L (mild hyponatremia).
rate with serum sodium ions increased by 1–2 mEq/L per
hour can relieve the symptom. Some authors believed that the best treatment for the
3. Increase in plasma osmotic pressure cannot exceed body fluid overload was to restrict water intake and promote
12 mOsm/L in 24 h. spontaneous diuresis, especially when patients had no obvi-
4. Dynamic monitoring of blood electrolytes and urinary ous symptoms. This treatment may be inappropriate for
output is needed. patients with severe hyponatremia, which may lead to rapid
5. Usually hypertonic saline solutions should not be used to deterioration of the symptoms. Arieff and Ayus reported that
correct hyponatremia, but correction with normal saline symptomatic hyponatremia occurred in 15 women who
could be extremely effective. Generally, 1/3 or 1/2 of the underwent surgery. Eight of the patients developed epileptic
sodium deficient is given at first so as to increase the seizures and respiratory inhibition without any warning.
osmotic pressure of extracellular fluid, transfer the water Because there is usually no warning before the attack of
from the intracellular to extracellular space, and restore these serious symptoms, immediate intervention should be
the cellular function. Observation of the patient is made taken. However, there is still much dispute over what is the
proper therapy. The consensus of the researchers is that the Plasma osmotic pressure cannot be corrected rapidly
serum sodium level should be corrected, but the correction because the intracellular spontaneous infiltration and K+
rate has always been the focus of dispute. Rapid correction release will last for a few days. Moreover, these ions re-enter
of sodium may lead to an intractable brain damage—central the cells more slowly than being discharged. CPM is consid-
pontine myelinolysis (CPM). CPM refers to a phenomenon ered to be caused by brain cells “shrinkage” due to the rapid
that after correction of hyponatremia, the symptoms of which correction of hyponatremia. Thus, CPM is also known as
would be firstly improved, but several days later, the patients’ “osmotic demyelination syndrome.”
neurological conditions may worsen, and the new clinical In addition, it is worthwhile to note that the mortality of
symptoms are completely different from the original symp- acute hyponatremia is much higher than that of chronic one.
toms caused by hyponatremia, which can even lead to death. When the serum sodium level is 120 mmol/L, acute hypona-
CPM was firstly defined and described by Adamas et al. tremia can lead to death, while the chronic one would not. If
As CPM progresses, patients may develop spastic quad- the low sodium state lasts for 48 h, it can be recognized as
riplegia, aphasia, pseudobulbar palsy, behavioral impairment chronic. Within 48 h, the brain cells can balance the hypo-
and movement disorders. Although the onset of symptoms tonic state through the release of solute. In an acute state, a
may occur 4 h after surgery, CT and MRI can help to make rapid correction of serum sodium rarely causes damage,
diagnoses in the early stage of pathological process. Autopsy because no “shrinkage” is developed in brain cells. Animal
ascribes the destruction of myelin sheath at pons and outside experiments showed that a rapid correction of serum sodium
the pons. In order to describe this pathological process more within 24 h was feasible and would not cause either the
accurately, Arieff recommended the name of “demyelination “shrinkage” of brain cells or demyelination disorders.
disorders.” Animal experiments have confirmed that too However, the same treatment for hyponatremia 3 days later
rapid correction of chronic hyponatremia can lead to brain can lead to the “shrinkage” of brain cells, demyelination dis-
demyelination, but gradual correction may prevent this orders, and death.
disorder. Hyponatremia induced by hysteroscopic surgery is an
Brain demyelination disorders induced by rapid correc- acute process. Close intraoperative and postoperative moni-
tion of hyponatremia are the corresponding pathological toring, timely diagnosis, and advance treatment should be
changes in brain tissues secondary to changes in osmotic administered, and it is not appropriate to limit the fluid intake
pressure. The brain can relatively resist osmotic swelling, solely and wait for spontaneous diuresis. Rapid correction in
because when the intracranial pressure rises, the brain tissue serum sodium levels often leads to overcorrection, and the
can discharge water into the cerebrospinal fluid. The capac- use of diuretics can usually cause hypernatremia. Minor
ity to drain water and avoid osmotic swelling is time depen- increase in plasma osmotic pressure can offset the hazards of
dent. In patients with hyponatremia, as the pressure in the cerebral edema. Assuming that the serum sodium concentra-
inter-tissue space increases, water is released into the cere- tion drops to 120 mmol/L, and if it is raised to 126 or
brospinal fluid by the effects of osmosis. Almost at the same 132 mmol/L (increase rate 5–10%), cerebral edema could be
time, the sodium and water is forced into the cerebrospinal effectively relieved. The serum sodium concentration can be
fluid through the extracellular channel, so the liquid then raised from 1 to 2 mmol/L per hour in the first several hours
enters the central nervous system. Secondary disorders of the and an increase in serum sodium concentration within the
brain occur at the cellular level. Unlike other tissues, brain first 24 h should be <12 mmol/L. If hyponatremia is not diag-
cells discharge intracellular solute in a hypotonic state. nosed in the postoperative 24–48 h, subsequent treatment
Intracellular K+ moves with the water from inside the cell to must be implemented cautiously so as to avoid CPM. If a
outside the cell within 3–4 h, and this movement may reach large amount of irrigating fluid was absorbed via perito-
a peak within 24 h. A few days later, there may be a loss of neum, a series of symptoms of hyponatremia would be
the cytoplasmic organic solutes (formerly called as “sponta- delayed, including cerebral edema.
neous infiltration”), including taurine, creatine phosphate, To prevent the development of CPM in the treatment of
and glutamate, and so on. chronic hyponatremia, some scholars believed that the serum
This adaptation to hyponatremia and low osmotic pres- sodium level could be raised by <25 mmol/L within first 48 h
sure can account for the changes of the brain in the rapid of treatment. Similarly, some scholars held that the correc-
correction of hyponatremia. In order to reduce the swelling, tion rate of serum sodium should not exceed 12 mmol/L per
the brain tissue achieves balance with plasma osmotic pres- hour. It is unnecessary to pursue the normal serum sodium
sure by reducing the intracellular solute content. If the level at the risk of overcorrection, and it is appropriate just to
plasma osmotic pressure increases quickly, the brain tissue reach the level of mild hyponatremia. The correction rate per
will dehydrate, because the rapid increase in osmotic pres- hour is still controversial currently. Earlier reports suggested
sure can lead to transfer of water from brain cells into plasma, that serum sodium levels should be slowly corrected, and the
causing brain dehydration. correction rate per hour be <0.6 mmol/L. Other reports indi-
60 L. Feng
cated that the hourly rate of correction was not important, but 2. About morphine: Morphine is suggested for patients with
excessively slow correction of the brain status could also heart failure and lung edema due to other causes.
lead to death. However, it is not appropriate if lung edema is caused by
In the treatment of acute hyponatremia, there are many TURP, because morphine may lead to the release of ADH
different ways, including intravenous infusion of normal (antidiuretic hormone), which reduces urine output,
saline, 3–5% sodium chloride and potent diuresis. aggravating water intoxication.
Hypertonic saline with concentration more than 5% is
strictly prohibited, which may worsen the body fluid over-
load further. Some scholars advocated substituting furose- 6.5.4 Treatment of Cerebral Edema
mide or mannitol for diuretics, of which mannitol was
preferred due to osmotic diuresis, and very small quantities 1. High concentration urea―osmotic diuretic: Intravascular
of Na+ in the urine might be lost. However just as hyper- fluid osmotic pressure is higher than that in tissues, thus
tonic saline, mannitol is an effective intravascular osmotic water enters from brain tissue into the blood vessels.
agent, which can also cause unnecessary increase in blood 2. Corticosteroid hormone―dexamethasone: It may stabi-
volume. For this reason, some people advocated the use of lize cell membrane, reduce capillary permeability, and
furosemide. The diuretic effect can work a few minutes relieve cerebral edema.
after intravenous infusion of furosemide. 20 mg is suffi-
cient to achieve the diuretic effect in patients with normal
renal function, but large doses of furosemide are required 6.5.5 Correction of Electrolyte Imbalance
for patients with renal insufficiency. The amount of urine
and urine sodium content should be accurately calculated, 1. Hypokalemia: Excessive use of diuretics may cause low
and a proper blood volume should be maintained in the potassium and arrhythmia, serum potassium should be
treatment. measured, and ECG monitoring should be taken.
2. Metabolic acidosis: pH value is measured and intrave-
nous drip of 4% sodium bicarbonate injection is
6.5.2 Treatment of Acute Heart Failure administered.
The patient is placed in a semi-sitting position, and digitalis

preparation is needed in addition to diuretics. Its principles 6.6 TURP Syndrome: Prophylactic
are to strengthen the cardiac contractility so as to increase Measures
the cardiac output and slow down the heart rate, and to pro-
mote peripheral vasoconstriction and hepatic venous con- Clinically, there are many effective ways to prevent exces-
traction so as to reduce venous return. Dosage: lanatoside C: sive absorption of the distention medium. First of all, no mat-
0.4 mg, slow intravenous injection; digitalis preparation: ter what kind of distention medium is in use, the absorption
1.0–1.2 mg, slow intravenous injection. should be closely monitored intraoperatively, and the volume
of fluid input and output must be accurately measured. An
resectoscope with double channels (i.e. the fluid inlet chan-
6.5.3 Treatment of Pulmonary Edema nel and the outlet channel are separated) should be used in
surgery, which can effectively allow outflow of the fluid
1. Treatment of hypoxemia: Oxygen uptake through nasal accumulating in the uterine cavity and also help drainage the
catheter is given at a flow rate of 6 L/min; mask oxygen fluid with vacuum aspiration. If not combined with laparo-
inhalation is administered to patients with obnubilation. scopic monitoring, the surgery under non-general anesthesia
If the above-mentioned treatment is ineffective and PO2 is is helpful in the observation of the complications, such as
under 50 mmHg, trachea cannula is suggested. If the nausea, vomiting, and altered mental status which may be
intermittent positive pressure breath at the beginning is suggestive of hyponatremia and foamy sputum which may
still ineffective, positive end expiratory pressure is rec- be suggestive of pulmonary edema. Moreover, the low tem-
ommended so as to increase the functional residual perature irrigating fluid can stimulate vascular contraction
capacity and effectively prevent the expiratory alveolar and reduce the absorption of distention fluid. If hystero-
collapse. Application of defoaming agent: during the scopic resection of uterine fibroids is to be undertaken, pre-
oxygen uptake through nasal catheter, 75–95% ethanol is operative administration of GnRH agonists can reduce the
put into the filter bottle and taken in together with the size of myoma and decrease the blood flow, which can be
oxygen, while 20–30% alcohol used in mask oxygen helpful to shorten the operative time and lower the volume of
inhalation. irrigating fluid. Finally, although the operative time is closely
related to the absorption of irrigating fluid and hyponatre- pressures. Some authors suggested keeping the fluid output
mia, many scholars believed that the operation should be ter- pipe unobstructed and the intrauterine pressure at
minated when excessive absorption of fluid was threatening 60–75 mmHg, which would be helpful for prevention of the
the safety of the operation, and another time should be fluid absorption. More attention should be paid especially
selected for a second operation. when the extent of surgery became greater.
When low viscosity distention medium is used, if the
absorption volume is greater than 500 mL, the surgeons
6.6.1 Prevention of Complications Caused by should closely observe the conditions of the lungs and check
High Viscosity Distention Medium the levels of serum electrolyte. The amount of fluid absorp-
tion should be accurately measured by the intake and outflow
The irrigating pressure of Hyskon, which is a high viscosity volume. Some scholars reported that there was an average
distention medium, should not be higher than 150 mmHg. decline in serum sodium concentration by 2.5 mEq/L
Pulmonary edema occurs when the input volume is >500 mL, (0–10 mEq/L)when the absorption volume of glycine was
so the absorption volume should be limited within <500 mL, and there was an average decline by 8 mEq/L
300 mL. The absorption volume of 300 mL can increase the (0–25 mEq/L) when the absorption volume was >500 mL. In
blood volume of 2900 mL, so the operative time should be this research, the absorption volume in two patients was
less than 45 min when Hyskon is used as distention medium. 2300 and 2700 mL, respectively, while the decrease in serum
sodium was 16 and 25 mEq/L, respectively.
6.6.2 Prevention of Complications Caused by

Low Viscosity Distention Medium 6.7 Equipment for Uterine Distention
with Fluids
When low viscosity distention medium is used, such as gly-
cine and mannitol solution, the absorption volume of fluid is In order to continuously monitor the inflow and the absorp-
easy to be underestimated, because the irrigating fluid usu- tion volumes of the fluid, the Olympus Cooperation designed
ally leaks from the cervix and the leaked fluid is often under- and produced a continuous flow irrigation pump. Its opera-
estimated or over calculated. Therefore, an accurate method tional principle is that the low viscosity irrigation fluid enters
of surveillance is needed. In order to monitor closely the bal- the uterine cavity through a rotating pump via resectoscope,
ance of body fluid, many scholars suggested adding ethanol the pressure and flow rate of the pump can both be previously
into the irrigating fluid to measure the ethanol content in set. The fluid flowing out of the uterine cavity is collected in
breathing so as to calculate the absorption of irrigating fluid. a container with scales. The difference between the inflow
In TURP syndrome, the amount of irrigating fluid absorp- and the outflow is the amount of absorption. These figures
tion is related to the weight of resected tissues and the dura- are all displayed on the screen of the monitor. If the amount
tion of operation and the pressure of distention. In of absorption is more than a certain standard volume (usu.
hysteroscopic surgery, the absorption of irrigating fluid is 1 L), the pump should sound the alarm in order to remind the
related to the intrauterine pressure, so the pressure should be surgeon to terminate the operation immediately.
confined to that achieving a clear vision. Mclucas held that The distending pressures of the pump range from 0 to
the distention pressure should be limited to 60 cm H2O 150 mmHg, and the flow rate range from 0 to 450 mL/min.
(44 mmHg). Istre et al. believed that it could be considered According to our experience, the pressure should be set at
as safe if the pressure was lower than 100 mmHg. Moreover, 100 mmHg and the flow rate at 200–250 mL/min, the aver-
some scholars believed the highest pressure in the uterine age intrauterine pressure could be at 70–75 mmHg. If the
cavity should be matched with the patients’ blood pressure. effect of distension is not satisfied, leading to a blurry opera-
The same irrigating pressure can produce different intrauter- tion field, the pressure can be set lower than the patient’s
ine pressure, which is also very important. Vulgaropulos systolic arterial pressure according to the blood pressure.
et al. discovered that the intrauterine pressure could continue Low pressure and high flow rate are the guarantee of safe
to be at a low level if the fluid outlet pipe remained to be hysteroscopic electro-resections.
open intraoperatively. On the contrary, if the fluid outlet pipe
was closed and the height difference of the fluid was 2.44 m
(8 ft) and 4.27 m (14 ft), the intrauterine pressure would be
230 and 280 mmHg, respectively. However, the author did
Suggested Reading
not think this pressure would lead to absorption of fluid since 1. Adams RD, Victor M, Mancall EL. Central pontine myelinolysis:
it only lasted for 30—60s, and the author did not describe a hitherto undescribed disease occurring in alcoholic and malnour-
clearly what operative procedures were done under these ished patients. AMA Arch Neurol Psychiatry. 1959;81(2):154–72.
62 L. Feng
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Anesthesia for Hysteroscopy
7
Handong Cai
Hysteroscopy is a new technique for treatment of gyneco- patient’s senses of security and trust, relieve the possible
logical diseases which was developed in 1990s. It integrates physical and psychological damage to the patient caused by
optical fiber, photoelectricity, mini camera, image analysis, fear and tension, and also figure out the operation site,
and imaging as a whole. When these high-tech instruments method, scope and position so that the anesthetic method,
are in clinical use, due to its characteristic technique, adverse equipment, and pharmaceutical preparations can be deter-
effects and severe complications may occur. Therefore, anes- mined. The patient should be told not to eat and drink 8–12 h
thetists must have sufficient knowledge related to this field before surgery, and both the patient and her family should be
and possess emergency treatment skills to deal with intraop- informed of the dangers of anesthesia, especially the occur-
erative accidents and complications. rence of an anesthetic accident, which might endanger the
patient’s life. Their understandings and written signatures
should be obtained before the surgery. As the legal system in
7.1 Pre-anesthetic Assessment our country has been gradually perfected, some hospitals
have already implemented a notarized signature on the con-
Although the pre-anesthetic assessment of hysteroscopy is sent for anesthesia, which is helpful in the implementation of
very similar to that of other surgery, large quantities of epi- anesthesia.
demiological studies showed that inadequate preparation
before surgery was one of the main causes of postoperative
complications and death. The saying “There is only a minor 7.1.2 Getting Familiar with the Patient’s
operation but no minor anesthesia” admonishes people to Medical History and Conducting
administer anesthesia cautiously and more importance a Systematic Physical Examination
should be attached to the pre-anesthetic assessment. The pre-
anesthetic assessment should be conducted as follows. The anesthetist must be especially clear about the patient’s
history of present illness and whether there is concomitant
medical diseases, such as heart disease, hypertension, diabe-
7.1.1 Preoperative Visits on Patients tes, liver and kidney disease, asthma, anemia, blood diseases,
and Participation in Preoperative blood coagulation disorders, and anticoagulant therapy,
Discussions whether they are already cured or still being treated, what
medications are used, the therapeutic reactions, any history
One to three days before the surgery, the anesthetist should of drug allergy, which are directly related to the safety of
go into the ward to visit the patient or participate in preopera- anesthesia. Much importance should be attached to the past
tive discussion. An anesthesia outpatient clinic should be history and family history, like whether the patient has
established in hospitals with better conditions so as to con- received anesthesia or not, its frequency, mode, and effect,
duct a pre-anesthetic assessment. This helps to establish the and whether her family has had hereditary diseases, myas-
thenia gravis or malignant hyperthermia, which is directly
related to the effects of anesthesia and prognosis. Therefore,
the patient’s general conditions must be systematically
examined before surgery, including vital signs, heart and
H. Cai (*)
Department of Anesthesiology, Fuxing Hospital, Capital Medical lung auscultation, extremities and spine, and nervous system
University, Beijing, China so that an anesthetic plan can be determined.

66 H. Cai
7.1.3 Examining and Checking the Essential pressure, nausea, vomiting, chest tightness, pale, sweating,
Laboratory Parameters and so on). Therefore, the anesthetic methods and choices
are determined by the following points:
1. Routine blood and urine test: It is mainly to find out
whether the patient is anemic or not, and the degree of 1. Whether diagnostic or therapeutic hysteroscope, flexible
anemia and functions of the kidney. or rigid.
2. Biochemical examination: It is to focus on the liver func- 2. Non-hospitalized or hospitalized patients.
tion, plasma protein, and albumin/globulin ratio, and 3. Whether the patients are cooperative mentally and
serum concentration of potassium, sodium, and glucose. psychologically.
Some medical treatments like cardiotonic, diuretic, and 4. The patients’ requirements for anesthesia.
hypoglycemic can lead to electrolyte imbalance. 5. The surgeons` requirements for anesthesia and profi-
3. Electrocardiogram (ECG) and chest X-ray: ECG and chest ciency in operation techniques.
X-ray are to understand the cardiac electrophysiological 6. Duration of operation.
activity, myocardial blood supply, and lung condition.
4. Other special examinations: Patients with heart and lung dis-
eases should undergo examination of lung function, cardiac 7.2.1 Topical Anesthesia
echocardiography, and blood gas analysis when necessary.
Patients with a history of blood disease and anticoagulant Topical anesthesia is a kind of anesthetic method by local
therapy must have blood coagulation function. spray of the anesthetics which has strong penetration and
immediate effect into the cervical canal or into the uterine
cavity. The commonly used medications are 0.5–1% tetra-
7.1.4 Assessment of Anesthesia Risks caine or 2% lidocaine by tamponade with cotton sticks into
the cervical canal or by injection into the uterine cavity.
Anesthetists should consider whether the patient receives anes- Although the topical anesthesia can relieve the pain caused
thesia in her best physical conditions before surgery, and whether by uterine dilation and systemic adverse reactions, it cannot
the benefits brought to the patient by this surgery are more than well relieve the nerve reflex symptoms during intrauterine
the risks of anesthesia for surgery induced by the coexistent ill- operation, because it cannot completely block up the nerve
nesses. Each of the following items may lead to complications reflex of submucosal layer and muscle layer to compression,
during and after surgery and increase the danger of death. stretching, and thermal effects of resection or coagulation.
However, combined with neuroleptanesthesia, this method
1. Clinical assessment of American society of can be used for hysteroscopic biopsy and examination,
Anesthesiologists (ASA) is above grade III. TCRP, and other minitraumatic procedures.
2. Heart failure, digitalis therapy, electrolyte imbalance.
3. Goldman’s cardiac risk index is >25.
4. Lung disease and pulmonary abnormalities confirmed by 7.2.2 Paracervical Nerve Block
chest X-ray.
5. Renal failure or metabolic acidosis. Paracervical nerve block is administered with the cervical injec-
6. Abnormal ECG. tion of 0.5 ml to 1 ml of 2% lidocaine at 4, 8, and 10 o’clock
7. Acute respiratory tract infection. position and 0.5 cm to outer edge of cervix with 3 cm deep of the
8. Severe anemia and hypoproteinemia. needle insertion, which can loosen cervical canal in 92% of
9. Blood diseases related to blood coagulation dysfunction patients and reduce the incidence of RAAS significantly.
and inevitable anticoagulation therapy. Theoretically the paracervical nerve block with high concentra-
tion and high volume can be more effective, but there exists
injection pain and systemic toxic reactions, and the nerve reflexes
7.2 Anesthetic Methods and Choices of the fundus and the corpus cannot be completely released.
for Hysteroscopy
Although hysteroscopy restricts its stimulation in cervical 7.2.3 Epidural Anesthesia and Subarachnoid
dilatation and intrauterine operation, since the splanchnic Block
nerves governing the uterus are mainly from the sympathetic
nerves of T10–12 and L1 & 2 and from the pelvic plexus com- Epidural anesthesia consists of continuous epidural anesthe-
posed of parasympathetic nerves of S2–4, it easily leads to sia and single epidural anesthesia, and is a widely used and
general reactions like reaction of artificial abortion syndrome skillful anesthetic method. It can modify the duration and the
(RAAS) (that is, bradycardia, arrhythmia, lowered blood level of anesthesia freely according to the length of operative
7 Anesthesia for Hysteroscopy 67
time and the doctor’s proficiency. The advantages are: (1) the safe and reliable, and the patients can wake up quickly after
block is perfect and can be easily controlled after successful operation. Alfentanil is especially good with perfect analge-
puncture; (2) it can release the stress reaction and reduce the sia, and can separate analgesia from consciousness, so the
occurrence of increased blood pressure and tachycardia; (3) patients seldom feel painful at the end of operation or have
the gastrointestinal peristalsis can be improved, the abdomi- any memory of the process of operation. It has a short acting
nal distention can be reduced, and the tension of parasympa- time, but may cause transient respiratory depression at a
thetic nerves is increased due to a sympathetic nerve block; large dose, most of which can be relieved spontaneously.
(4) the patients remain conscious during operation so they
can tell about the possible adverse effects immediately, such 1. Etomidate: Etomidate is the derivative of imidazole.
as TURP syndrome; (5) nausea, vomiting, and lethargy are Given a dose of 0.1–0.3 mg/kg, a patient may wake up
decreased after operation; (6) it can also be used to provide naturally in 7–14 min, without any mental disorders but
analgesia after operation. However, there are also some dis- high incidence of vomiting. The patient may feel pain at
advantages. The failure rate is higher because of the higher the injection position and may have body movement as
requirement for skills in anesthetic procedures. The onset well. This drug can also inhibit the adrenal cortex func-
time for anesthesia is relatively longer and there’s possibility tion. If used together with low dose of fentanyl, etomidate
of total spinal anesthesia. Some patients may have coagula- can produce perfect analgesia, immediate wake up, and
tion disorders, hemodynamic instability or spinal deformity, fewer side effects.
which should be contraindications for epidural or spinal 2. Propofol: Propofol works quickly and has a short dura-
anesthesia. Although the subarachnoid block can be easily tion. The patients may recover quickly and smoothly,
administered and perfect block can be achieved, it is not suit- meanwhile, this drug is antiemetic to a certain extent. The
able for the non-hospitalized patients, and it can produce commonly used dosage is 2.5–3 mg/kg, which can last
great effects on hemodynamics, especially in the young and 8–10 min. After first administration, an intravenous drip
adults. Due to a higher incidence of postoperative headache, of 3–4 mg/(kg·h) is given continuously, which can option-
it is rarely used clinically. ally prolong the duration of anesthesia without changing
the time of waking up. However, there has also been tran-
sient respiratory and circulatory depressions. Therefore,
7.2.4 General Anesthesia the anesthetists are required to be armed with the assisted
ventilation equipment and techniques.
Hysteroscopic surgery is limited inside the uterine cavity and 3. Alfentanil: The potency ratio of alfentanil to fentanyl is
the operation time is shorter, so general anesthesia is not nec- 8:1, and its onset of effects and the duration of action is
essary. However, with the improvement of people’s life qual- 1/3 of that of fentanyl. Alfentanil does not accumulate,
ity, knowledge, and awareness, more and more patients has little influence on cardiovascular system, and sepa-
demand to spend the perioperative period quietly, smoothly, rates the analgesic effect from the patient’s conscious-
and painlessly, so general intravenous anesthesia is usually ness. The usual dosage is 30–50 μg/kg and the analgesic
adopted. The anesthetic agent should be selected with a short effect maintains for 15–20 min.
acting time, rapid recovery, good analgesic effect, and few 4. Ketamine: It has strong analgesic effect with the usual
side effects. Ketamine in sub-anesthetic dose was adopted dosage at hysteroscopy 0.3–1.3 mg/kg, and it is adminis-
more often in the past, which had the analgesic effect of tered via intravenous injection after dilution. Ketamine
80–90%. However, it could not totally inhibit RAAS, and an with such a sub-anesthetics dose has little influence on
increase in muscular tension might cause difficulty in uterine breathing with rapid wake up time, but its disadvantages
dilatation. Vomiting and more secretions in oral cavity and include muscle tension, vomiting, more respiratory secre-
respiratory tract are more likely to cause upper airway tions, excitement, nightmares, and so on.
obstruction and aspiration. And the patients may become 5. Remifentanil: It is an ultrashort acting opioid μ-receptor
excited, dysphoria, develop nightmare, and disturbance in agonist, with features of prompt onset of effect, short
psychology, so ketamine is rarely used now. duration of action, and no accumulation, so it is widely
used clinically. Its advantages are that it is metabolized
7.2.4.1 Intravenous Anesthesia and eliminated rapidly with t1/2Keo1 3–4 min; it is metab-
With the development and application of new intravenous olized through non-specific plasma and tissue esterases
anesthetics in recent years, clinical anesthesiologists can so it can be safely used in patients with liver and kidney
choose general anesthetic drugs more flexibly in according dysfunction. Its analgesic potency is 50–100 times that of
to the patient’s condition. The more commonly used anes-
thetic drugs in China are etomidate and propofol, while a 1
Keo, the rate constant of medicine transferring from effect compart-
single dose of alfentanil or sufentanil is more frequently used ment to central compartment; t1/2keo, half-time of equilibration between
abroad. These anesthetics have relatively fewer side effects, drug concentration in the blood and effect compartment.
68 H. Cai
fentanyl and 20–50 times that of alfentanil. The usual rence of cough is lessened and the oxygen saturation is
dosage of Remifentanil is 0.25–1 μg/kg via intravenous increased at recovery period, and the occurrence rate of throat
drip, and its analgesic effect may last 3–10 min. Larger pain after operations in adult is reduced.
dosage or too fast intravenous drip may also result in bra- For various hysteroscopic operations such as removal of
dycardia, nausea, vomiting, and respiratory depression. submucous fibroid, severe intrauterine adhesions, endome-
6. Target-controlled infusion (TCI) of propofol-opioid: trial polyps and hyperplasia, and congenital uterine abnor-
With the development of computer technology, in 1992, malities, due to their long duration of procedures, LMA
Kenny et al. produced computer-assisted titration intrave- should be inserted under intravenous anesthesia to ensure the
nous anesthetics and microcomputer-controlled infusion effective ventilation. In addition to ensuring the ventilation,
pump, which target the plasma or effect compartment as it can also reduce the possibility of both reflux and aspira-
the regulation index and simultaneously display the target tion, and perform mechanical ventilation and inhalation
plasma concentration, the effect compartment concentra- anesthesia. However, it is necessary to obtain the indications
tion, the administration time, and the cumulative dose, of LMA. Patients who have the probability of reflux and
and the maximum dosage can be restricted as well. At aspiration, including maxillofacial or oropharyngeal defor-
present, target-controlled infusion of propofol-opioid has mation, adenoidal hypertrophy, and satiety intestinal obstruc-
been widely used in clinical anesthesia and analgesia. tion, should be considered to be absolute contraindications.
There are two kinds of commonly used TCI systems, that
is: Diprifusor and Fresenius base primea, which can 7.2.4.3 Inhalation Anesthesia
administer dual or multichannel target-controlled infu- Some of hysteroscopic surgery may be completed under sim-
sion of analgesia-sedatives. Nowadays, the target- ple inhalation anesthesia. The anesthetic gas is taken with a
controlled infusion of propofol-remifentanil is usually certain concentration via respiratory tract to keep a proper
used with propofol 0.8 μg/L and remifentanil depth of anesthesia. At present, the inhaled anesthetic gas is
0.2–2 μg/L. They have better analgesic and sedative nitrous oxide, and the volatile agents are fluorine-containing
effects, and is also suitable for examination and surgical anesthetics including enflurane, isoflurane, sevoflurane, des-
treatment for old and weak women or women with more flurane, etc. Because nitrous oxide has a weak anesthetic
complications. effect and a risk of oxygen lack when being taken at a high
concentration, it is hardly used by itself to maintain the anes-
7.2.4.2 General Anesthesia Using Laryngeal thesia. The volatile anesthetics (e.g. sevoflurane, desflurane)
Mask Airway has a strong anesthetic effect and cause the patient to lose her
Laryngeal Mask Airway (LMA), which was developed by consciousness and sense of pain when being taken at a high
British anesthesiologist Dr. Brain in 1981, was an artificial concentration, so it can maintain the anesthesia on its own.
airway device basing on the study of the anatomy of the However, its muscle-relaxing effect is not satisfying. If the
adult’s upper airway. LMA is divided into three categories muscle-relaxing effect was blindly pursued, an anesthetist
according to its sequence of development and its applications: certainly would increase the concentration of inhalation
the first generation is a simple airway tube; the second gen- drugs. The higher the concentration of inhalation drugs are,
eration is intubating LMA (LMA-Fastrach); the third genera- the more serious the influence of it on physiology is.
tion is LMA double tube (ProSeal-LMA). The advantages of Therefore, nitrous oxide (N2O) is often administrated in
LMA are: (1) it is convenient and speedy to use, and easy to combination with oxygen (O2) clinically, with the concentra-
maintain the airway; (2) it does not need a laryngoscope, and tion of nitrous oxide 50–70%. The concentration of the vola-
there are less difficulty and higher success rate for beginners tile anesthetics can be regulated as required and adding some
when compared with tracheal intubation; (3) for long time muscle relaxants when muscle relaxation is needed. Muscle
operations without the requirement of relaxing the muscles, relaxants cannot only relax the muscles, but also enhance the
LMA takes over the function of a mask; (4) it can establish an anesthetic effect so that it can reduce the influence of deep
airway so as to permit a spontaneous or a controlled ventila- anesthesia to physiology. When nitrous oxide is applied, the
tion; (5) the patency of the airway can be maintained even if flow meter of anesthesia machine must be precise. The frac-
the position of LMA is not optimal; (6) the damage to mucous tion of inspired oxygen and oxygen saturation (SPO2) should
membrane of the trachea is avoided; (7) the patient can toler- be monitored with the fraction of inspired oxygen no more
ate the LMA at a lighter level of anesthesia, which need less than 30% being considered as safety. Volatile anesthetics
dosage of anesthetic than an endotracheal catheter; (8) the should adopt special evaporator to control the concentration
stability of hemodynamics is increased during the anesthetic of inhalation. The concentration of the anesthetics should be
induction and recovery period, the degree of increased intra- monitored continuously if it is possible, which permit a bet-
ocular pressure is reduced when inserting the tube, the occur- ter control of the depth of anesthesia.
General anesthesia with endotracheal intubation can be 7.3.1.4 Auscultation in the Precordium
performed if it is necessary so as to ensure the patient’s and Inside the Esophagus
safety. Heart sounds, respiratory rate, and ventilation can be moni-
tored but the respiratory mode cannot be recognized. When
gas is used for uterine distention, gas embolism can be easily
7.3 Intraoperative Surveillance During induced, which can be detected early by this kind of ausculta-
Hysteroscopic Surgery tion. If abnormal breath sound and heart sound are detected
with auscultation, the operation should be terminated immedi-
The specificity of anesthesia for hysteroscopy lies in that the ately and timely treatment should be given without any delay.
anesthesiologists should know about some potential adverse
reactions (such as TURP syndrome) and complications
related to surgical operation. Therefore, through surveillance 7.3.2 Special Monitoring
and analysis of the physiological parameters and its changes,
the anesthesiologists may detect the problem as early as pos- 7.3.2.1 Monitoring of Electrolyte
sible, judge its seriousness, and provide early diagnosis so as It is mainly the monitoring of the sodium concentration. 98%
to provide better anesthetic support and physiological pro- of osmotic pressure is provided by electrolyte, in which
tection for treatment of surgical complications. sodium takes up almost half. Nausea and discomfort will
occur if sodium concentration is <125 mmol/L; headache,
fatigue, and unresponsiveness will occur if it is between
7.3.1 Routine Monitoring 110 mmol/L and 120 mmol/L; convulsions and coma will
occur if it is <110 mmol/L. During hysteroscopic resection
7.3.1.1 Electrocardiogram (ECG) of uterine fibroids, if the uterine distension pressure is
ECG need to be routinely monitored in the elderly or the >100 cmH2O at a large perfusion flow rate or the patient is in
patients with congenital or acquired heart disease. Due to the a state of low blood pressure, dilutional hyponatremia is apt
influence of electric cutting or electrocoagulation on cardiac to occur, which may provide a sound basis for prevention
electrophysiology in the process of anesthesia and operation, and treatment of acute water intoxication.
ECG can detect the changes in myocardial ischemia and car-
diac arrhythmia as early as possible. 7.3.2.2 Blood Glucose Monitoring
There are three kinds of uterine distending media for hyster-
7.3.1.2 Blood Pressure oscopy. The commonly used fluid presently is 5% glucose,
Blood pressure is determined by the cardiac output, blood so it is quite necessary to determine the blood glucose con-
volume, and systemic vascular resistance. Hypotension may centration quickly at regular time interval. Once there is sig-
occur due to relatively insufficient blood volume after the nificant increase in the blood glucose, it is suggestive of
spinal anesthesia, and hypertension would result from high excessive absorption of irrigating or distending fluid.
blood volume if the operative time is long and the perfusion
pressure is high when fluid is used for uterine distention. 7.3.2.3 Monitoring of Central Venous Pressure
Once hypertension or hypotension occurs, the anesthesiolo- (CVP)
gists should determine the underlying cause as early as pos- An increase in CVP indicates the increase in effective blood
sible so as to administer the correct treatment. volume, and there is an earlier change in CVP than in blood
pressure, which can be accordingly taken as the pre-symptom
7.3.1.3 Monitoring of Pulse Oxygen Saturation of dilutional hyponatremia. However, its sensitivity is not the
(SpO2) same as in monitoring of pulmonary capillary wedge pres-
It may detect hypoxic hypoxia and pulsatile blood flow, and sure (PCWP), so it would be safer to instruct the treatment if
displays continuously gas exchange in the lungs, such as oxy- it is in line with the monitoring of PCWP.
hemoglobin saturation and central oxygenation status. Quite
a few gynecologic patients are anemia when they have hyster- 7.3.2.4 Noninvasive Estimation of Extravascular
oscopy. If the patient’s hemoglobin is 5–6 g, the oxygen con- Lung Water (EVLW)
tent will be insufficient but the oxygen saturation will be Any changes in capillary wall filtration and differences
satisfactory; if the patient suffers from hypotension or low between capillary internal and external hydrostatic pressure
cardiac pump function, the pulsatile blood flow will decrease and colloid osmotic pressure caused by any reasons may all
but the oxygen saturation will be normal. Therefore, there is lead to pulmonary edema monitoring of the thoracic fluid
less value and fewer importance for oxygen saturation in the index (TFI) by use of impedance cardiogram (ICG) can dis-
diagnosis of anemic anoxia and early hypotension. tinguish cardiogenic edema from noncardiogenic edema.
70 H. Cai
7.4 Prevention and Treatment 90 mL/s could be produced when the pressure gradient
of Complications During between vein cut and distending pressure was >4 mmHg.
Hysteroscopy Obvious symptoms would appear if it was absorbed by air
bubbles [0.5 mL/(kg·min)]. And it may cause death in
The following complications are usually found out by anes- patients with poor cardiac function. Its main manifestations
thetists first. are abnormal ECG and blood gas values, hypotension, char-
acteristic heart murmurs—metal murmur or water-wheel
murmur. Once suspected gas embolism occurs, uterine cav-
7.4.1 Mechanical Injury ity distension should be stopped immediately, and the surgi-
cal position should be changed to left lateral decubitus
The statistical data showed that the incidence of uterine perfo- position or head-down tilt position in order to elevate the
ration was about 2% in hysteroscopic examination and surgery, venous pressure, and the bubbles should be suctioned via
which resulted from physiological and pathological causes, right heart catheter when necessary.
including those being related to abnormal positions of the
uterus, such as anteverted or retroverted uterus, anatomical
abnormalities, uterine atrophy or hypoplasia, intrauterine adhe- 7.4.4 TURP Syndrome
sions and cervical stenosis, and also those being related to
unsatisfactory uterine distension during surgical operation. Excessive absorption of uterine distending fluid during hys-
Uterine rupture can occur due to cervical perforation and tear- teroscopy under the elevated pressure may also lead to acute
ing, and creation of false passages, during the process of cervi- water intoxication which is similar to TURP syndrome. The
cal dilation or intrauterine operation. For instance, if perforation occurrence of TURP syndrome is subject to the type of dis-
occurs due to electrocautery, electroresection, laser knife or tention fluid, as well as the amount and the rate of absorp-
some sharp instruments, the damaged sites might not heal tion. Acute water intoxication is mostly caused by
spontaneously; if the perforated sites were near the uterine cor- intravascular absorption, that is, the distending medium
nua and adnexa, heavy bleeding may occur because of the rich directly enters the blood vessels via injured small vein or
blood supply; if a large amount of distention medium (gas or sinusoids. However, the absorption of distention fluid via
fluid) was absorbed into the circulation, metabolic, and circula- defective endometrium or extravascular absorption of disten-
tory disorders such as anemia could happen. As a result, the tion fluid which enters the abdominal cavity via fallopian
surgeons must cautiously select suitable patients undergoing tubes can promote the hypotonic solution into the extravas-
hysteroscopy, master the hysteroscopic instruments skillfully, cular space, resulting in delayed hyponatremia.
use uterine distention pump with adjustable flow rate to expand The amount and the rate of fluid absorption are determined
the uterine cavity, so that they can achieve an optimal surgical by the following situations. (1) pressure of distention fluids: It
view and improve the safety of surgery. is a key factor for the amount of absorption. Large amounts of
distention medium can also be absorbed even if the pressure
is less than 60 cmH2O. And an equally important factor is the
7.4.2 Bleeding duration of pressure. (2) Operative time: The duration of
operation is mainly related to the amount of intravascular
Heavy bleeding induced by hysteroscopy is relatively rare absorption. It is generally believed that severe TURP syn-
unless there is simultaneous uterine perforation. However, drome would not occur if the operative time is within 60 min,
some patients are suffering from coagulation disorders or but there is also a report on the occurrence of acute water
have been taking non-steroidal anti-inflammatory drugs and toxication only 15 min after the start of surgery. (3) The vol-
anticoagulant therapy due to cardiovascular diseases for a ume of the fibroids and the area of the endometrium to be
long term, especially aspirin, which may lead to heavy bleed- resected. (4) Blood loss: The amount of distention medium
ing. Coagulation disorders should be treated preoperatively, absorption is positively correlated with blood loss, as the flow
and surgical treatment can be administered in patients only rate of perfusion fluid needed is also larger when there’s more
after 7–14d discontinuation of aspirin. Some literatures blood loss. (5) the looseness of cervical canal and the opening
reported that the duration of discontinued use of aspirin degree of the outflow stopcock of hysteroscope: Poor drain-
should be more than 20 days. age and elevated intrauterine pressure can also lead to great
volume and fast rate of fluid absorption.
Generally speaking, elevated blood pressure, slow pulse,
7.4.3 Gas Embolism and mentally abnormal excitement are the three early signs
of acute water intoxication. Significant decrease in plasma
It mostly occurs in cases using gas (CO2) as uterine distend- colloid osmotic pressure can lead to noncardiogenic pulmo-
ing medium. Some literatures showed that a gas flow of nary edema, and the patient will manifest as hypoxemia,
such as shortness of breath, pink frothy sputum, lips cyano- limited, and colloidal solution should be given appropri-
sis, and so on. Serious reduction in serum sodium concentra- ately together with 40% ethanol atomization oxygen
tion can lead to low electrolyte cardiovascular collapse, and inhalation.
the patient will manifest as hypotension, headache, nausea, 4. Maintaining a lower intraoperative distention pressure at
vomiting, blurred vision, disturbance of consciousness, and about 60 cmH2O whenever possible, using non-hemolytic
even tonic convulsions and coma if not treated in time. isotonic or hypotonic uterine distention medium and
Once TURP syndrome occurs, operation should be shortening the operation time as far as possible are the
stopped immediately, the normal blood volume should be main measures for prevention of TURP syndrome.
actively recovered, and the venous return should be reduced.
The serum sodium concentration and plasma osmotic pres-
sure should be monitored frequently, and excessive water
should be excreted so as to correct hyponatremia. Suggested Reading
1. Gustorff B, Hoechtl K, Sycha T, Felouzis E, Lehr S, Kress HG. The
1. Application of furosemide: The volume of distention effects of remifentanil and gabapentin on hyperalgesia in a new
fluid absorption dilutes the Na+ in the blood, which inhib- extended inflammatory skin pain model in healthy volunteers.
its the diuretic action of the osmotic diuretic substances Anesth Analg. 2004;98(2):401–7.
2. Jeffery LP. Complications of endoscopic and laparoscopic surgery.
in distention fluid. Therefore, furosemide should be given
New York: Lipincott Raven; 1997. p. 233–41.
routinely and cardiac therapy is necessary if the patient is 3. Liu X, Cao J, Zheng L. Clinical anesthesia implementation pro-
with severe pulmonary edema. gram. Bei Jing: The People’s Medical Publishing House; 2000.
2. Application of hypertonic saline solution: 3–5% sodium p. 94–9. Chinese.
4. Viviand X, Fabre G, Ortéga D, Dayan A, Boubli L, Martin C. Target-
chloride solution can be used to correct the abnormal
controlled sedation-analgesia using propofol and remifentanil
blood volume and hyponatremia, and can also have a in women undergoing late termination of pregnancy. Int J Obstet
function of osmotic diuresis so as to relieve the intracel- Anesth. 2003;12(2):83–8.
lular edema. 5. Wiebe ER. Comparison of the efficacy of different local anaesthet-
ics and techniques of local anaesthesia in therapeutic abortions. Am
3. In case of non-cardiogenic pulmonary edema, the patient
J Obstet Gyneol. 1992;167(1):131–4.
may have great amounts of pink frothy sputum and cya- 6. Wiebe ER, Rauling M. Pain control in abortion. In J Gynecol
nosis. The transfusion of crystalloid solution should be Obstet. 1995;50(1):41–6.
Diagnostic Hysteroscopy
8
Enlan Xia and Dan Yu
Diagnostic hysteroscopy can be used to directly investigate considered as a routine method for diagnosis of intrauterine
intrauterine lesions and localize them for biopsy, so it is lesions in the twenty-first century.
more intuitive, accurate, and reliable than traditional diag-
nostic dilatation and curettage (D&C), hysterosalpingogra-
phy (HSG), and ultrasonography. Hysteroscopy can reduce 8.1 Hysteroscopy
the rate of missed diagnosis, significantly improve the
accuracy of diagnosis, and has been reputed to be the Enlan Xia and Dan Yu
golden standard of modern diagnosis of intrauterine lesions.
Dotto et al. classified the endometrial images under hys-
teroscope into five categories: normal endometrium, benign 8.1.1 Indications for Hysteroscopy
lesions, low-risk endometrial hyperplasia, high-risk endo-
metrial hyperplasia, and endometrial cancer, which were Any intrauterine pathologies which are suspected in any
highly consistent with the findings of endometrial biopsy. form or need to be diagnosed and treated are indications of
Clark et al. reviewed 65 articles and studied the accuracy of hysteroscopy.
hysteroscopy in diagnosis of endometrial cancer and hyper-
plasia in women with abnormal uterine bleeding. They 8.1.1.1 Abnormal Uterine Bleeding (AUB)
found that in all patients included, the pretest probability of It is abnormal bleeding occurring in women of child-bearing
endometrial cancer was 3.9%, which was increased to age, or in perimenopausal women and postmenopausal
71.8% by a positive result of hysteroscopy and was reduced women, which includes menorrhagia, epimenorrhea, pro-
to 0.6% by a negative result. Thus, it was considered that longed menstruation, irregular bleeding, and pre-menopausal
the accuracy of hysteroscopy for endometrial cancer was and post-menopausal uterine bleeding, all of which are the
high, but was only applicable to endometrial disease. main indications for hysteroscopy. Nagele et al. reported that
Agostini et al. made a review and analysis of 17 cases who AUB was the most common indication for hysteroscopy
were diagnosed pathologically to have endometrial atypical (87%). For women of child-bearing age with abnormal
hyperplasia after hysteroscopic resection. One case was bleeding, abnormal pregnancies, such as threatened abor-
discovered to have endometrial adenocarcinoma, with the tion, ectopic pregnancy, etc. should first be excluded. As for
risk of 5.9% (1/17). Nowadays, diagnostic hysteroscopy pre-menopausal and post-menopausal abnormal bleeding,
has become a new and valuable gynecological diagnostic the patient should be alerted to the possibility of endometrial
technique. Applications of micro-devices and non-invasive carcinoma and the uterine-distending pressure cannot be too
techniques have expanded the use of hysteroscopy from high during hysteroscopy so as not to cause the cancer cells
out-patient clinic to movable stations. Nagele et al. sug- to spread into the abdominal cavity.
gested that outpatient hysteroscopy had a high detection
rate for intrauterine lesions and simple hysteroscopic sur- 8.1.1.2 Abnormal Sonographic Findings
geries could be performed at the same time. Therefore, just in Uterine Cavity
as D&C in the twentieth century, hysteroscopy has been A number of imaging techniques such as ultrasound, HSG,
CT, MRI, sonohysterography (SHSG), saline infusion sono-
hysteroscopy (SIS), and television color doppler (TVCD)
E. Xia (*) · D. Yu may be used to indirectly visualize the endometrial activity.
With diagnostic hysteroscopy, intrauterine lesions can be
Beijing, China

74 E. Xia and D. Yu
directly identified, evaluated, and located, while the sus- 8.1.1.8 Uterine Myomas
pected lesions can be biopsied for histological and cytologi- When an operation is to be determined in a patient with mul-
cal examination. As for patients with infertility and recurrent tiple myomas, hysteroscopy should be used to detect the
pregnancy loss, under hysteroscopy, anatomical morphology existence of submucous myomas.
of the uterine cavity and the tubal ostia should be observed to
see whether there are uterine malformations, intrauterine 8.1.1.9 Examination of Intrauterine Device
adhesions, submucous myomas, etc. In addition, the mucosa Hysteroscopy can be used to observe the location of IUD,
of endometrium should be observed to see whether there is and detect whether there is embedment.
endometrial hyperplasia or endometrial polyp, and target
biopsy should be done on suspected areas. 8.1.1.10 Abnormal Vaginal Discharge
Patients with endometrial cancer sometimes visit the hospi-
8.1.1.3 Infertility tal due to abnormal vaginal discharge. In Fuxing hospital,
Intrauterine factors for infertility can be found under hyster- ultrasonography showed no abnormality in a patient who has
oscopy. Li analyzed the results of diagnostic hysteroscopy in had vaginal discharge of colorless and transparent liquid for
259 patients with infertility. The results showed that 120 2 years. High-differentiated adenocarcinoma was confirmed
cases (46.33%) had intrauterine lesions, with endometrial by diagnostic hysteroscopy.
polyps in 42 cases (35%), uterine malformation in 37 cases
(30.83%), intrauterine adhesions in 23 cases (19.17%),
endometrial diseases in 10 cases (8.33%), intrauterine for- 8.1.2 Contraindications for Hysteroscopy
eign body in one case (0.83%), and submucous myoma in 6
cases (5%). 8.1.2.1 Absolute Contraindications
It has been said that there were no absolute contraindications
8.1.1.4 Physiological or Characteristic Changes for diagnostic hysteroscopy. As the procedure of hysteros-
Caused by Tamoxifen or Hormone copy would spread the inflammation, some surgeons consid-
Replacement Therapy (HRT) ered the following points as absolute contraindications. In
Due to the estrogen effect of the drugs, long-term use of these cases, anti-infective treatment should be given firstly,
tamoxifen or estrogenic hormones can lead to endometrial and the hysteroscopy deferred until the infection is
hyperplasia, formation of polyps, and even endometrial car- controlled.
cinogenesis, which need assessment under hysteroscope.
Abnormal findings of endometrial aspiration cytology or 1. Acute endometritis.
endometrial histopathology. Sometimes hysteroscopy is 2. Acute salpingitis.
needed for localization of the lesions and sampling. 3. Acute pelvic inflammatory disease.
8.1.1.5 Secondary Dysmenorrhea 8.1.2.2 Relative Contraindications

It is often caused by intrauterine abnormalities including Some scholars did not consider the following conditions as
submucous myomas, endometrial polyps or intrauterine contraindications but only as precautions during hysteroscopy.
adhesions, and hysteroscopy should be the preferred diag-
nostic method. 1. Massive uterine bleeding: The vision of hysteroscopy
may be all covered by blood when there are heavy bleed-
8.1.1.6 After Complex Intrauterine Operations ing, which not only makes lesions difficult to be detected,
Secondary hysteroscopy is done 6–8 weeks after the original but also increases bleeding.
operation so as to diagnose and divide early filmy 2. Pregnancy: The hysteroscopy may cause abortion.
adhesions. 3. Chronic pelvic inflammatory disease: The hysteroscopy
may cause the spread of inflammation.
8.1.1.7 Staging of the Endometrial Carcinoma
Diagnostic hysteroscopy can be used to observe whether
there is any invasion on the mucosa of the cervical canal. 8.1.3 Preoperative Evaluation
Garuti et al. reported that the predictive values of hysteros-
copy on cervical spreading of endometrial carcinoma had a Comprehensive evaluations and preparations should be done
sensitivity of 100% and specificity of 87.3%. Hysteroscopy on patients who are going to undergo hysteroscopy, which
was highly accurate in excluding the spread to cervix. includes the confirmation of examination indications:
8 Diagnostic Hysteroscopy 75
whether the patient has hypertension or diabetes, whether the 8.1.4 Uterine Distention System
patient can tolerate the discomfort caused by a relatively lon- in Hysteroscopy
ger period of lithotomy position and uterine distension, the
degree of cervical relaxation, whether there are risk factors Under normal conditions, the anterior and posterior walls of
such as damage and infection of viscera, whether it is possi- uterine cavity are close to each other. So the observation of the
ble to be treated in one procedure, etc. Therefore, decision uterine cavity can only be achieved when the uterine cavity is
should be made on whether an anesthesia is needed and distended artificially by injection of the distending medium.
which is the best anesthesia; selecting and preparing the
equipment, and whether it is necessary to use prophylactic 8.1.4.1 Fluid Medium for Uterine Distention
antibiotics; etc.
Uterine Distending Equipment
8.1.3.1 Patient’s History An infusion bottle may be used to connect with the inflow
The patient’s general condition and past history should be pipes and distend the uterine cavity with the pressure pro-
inquired in detail, and attention should be paid to whether the duced by gravity, that is, the height difference between the
patient has suffered from some important viscera diseases, cavity and the fluid surface. Or an automatic fluid uterine-
such as heart, lung, liver and kidney, etc.; and whether there distending pump can be used to distend the cavity, with
is a bleeding tendency or a history of diabetes. In addition, which the pressure and the flow rate can be set to keep the
the possibility of pregnancy must be excluded before opera- uterine cavity expanded continuously. The distending pres-
tion in patients with irregular menstruation. sure should be set less than 100 mmHg. If there is no auto-
matic distension pump and the uterine cavity had to be
8.1.3.2 Physical Examination distended by the pressure caused by liquid level differences,
Blood pressure, pulse, and temperature should be routinely the compression belt or the three-tee tubes could be used to
measured and the cardiorespiratory function should be elevate the pressure when it is not high enough.
checked. Attention should be paid to whether there is pelvic
inflammation and acute vaginitis. For patients with inflam- Distention Medium
mation, treatment must be administered first, and hysteros- Sufficient distension of the uterine cavity and clear bloodless
copy cannot be performed until the inflammation is vision are the important factors for hysteroscopic examina-
controlled. tion and surgery. The fluid distention medium cannot only
expand the uterine cavity, but also flush the objective lens so
8.1.3.3 Laboratory Examination as to avoid being stained by blood, mucus, and intrauterine
Routine urine and blood tests should be done. If the patient’s floaters, thus the field of view is kept clear.
urine glucose is positive, the fasting blood glucose should be
measured so as to choose a proper distending fluid. The tests 1. Normal saline: It is isotonic solution, with the refractive
of the vaginal secretions include cleanliness, candida, tricho- index of 1.37, and can wash away the intrauterine debris
monas, etc. If necessary, cervical secretions should be taken and blood clot easily, but it has a worse viscosity and can
to detect chlamydia pneumoniae, mycoplasma pneumoniae, be blended with the blood easily, which affects the field
and neisseria gonorrhoeae. Routine examination of the cervi- of view.
cal cytology and some indicators such as liver and kidney 2. 5% glucose solution: It has a relatively high viscosity and
function, and hepatitis B surface antigen should be carried clear field of view, but it makes the surfaces of equipment
out. and gloves sticky when used, which is uncomfortable.
3. Hyskon solution: It is a high-viscosity uterine distending
8.1.3.4 Psychological Counseling medium, and is a mixture of 32% dextran-70 and 10%
Doctors should carefully explain the process of hysteroscopy glucose. Its advantages include high viscosity, fewer
and the necessity of hysteroscopy so as to get the patient’s amount used, not easy to mix with blood and mucus, and
understanding and cooperation, which may be helpful in it is especially applicable to patients with metrorrhagia.
getting a satisfactory diagnosis result and successful com- The disadvantages are its expensiveness, difficulty in
pletion of operation, and even reduce the demand for anes- cleansing, and that all equipment must be soaked in hot
thesia. It has ever been said that the doctors’ explanation is water after being used so as not to form deposit on the
the best medicine and the noninvasive technique is the best surface of the pipes or the lens because the deposit could
anesthesia, which supports the importance of psychological lead to damage of the equipment easily. Moreover, there
counselling. had also been reports of cases with allergy.
76 E. Xia and D. Yu
8.1.4.2 Gas as Uterine Distention Medium Table 8.1 Comparison of distention media between CO2 and fluid
1. Uterine distending equipment: When an automatic CO2 Items CO2 Fluid
insufflation machine is used (Fig. 8.1), the distention Definition of image Relatively Good
pressure and flow rate can be controlled and regulated good
according to the requirement of the procedures. When Angle of view Wide Relatively
narrow
CO2 was originally used to expand the uterus, gas embo- Hysteroscopic embryo Applicable Not
lisms had occurred which resulted in death in some cases. transplantation or artificial tubal applicable
The invention of CO2 insufflator has greatly increased the insemination
safety of CO2 distention, which is now very popular and Examination when bleeding Difficult Easy
mostly used in Europe and America. The flow rate of CO2 Insertion of the scope under direct Difficult Easy
vision
insufflation is set at 30–80 mL/min and the pressure is set
Observation of blood vessels in the Difficult Easy
below 100 mmHg. During the hysteroscopic procedures diseased area
with CO2 insufflation, if there is intrauterine bleeding, the Difficulty in observation induced by Often occur No
objective lens would be contaminated by blood, which bubbles
could not be removed and would make the observation Contamination of objective lens Often occur Few
impossible, and this is its shortcoming. Observation of myomas or polyps in Difficult Easy
the posterior wall of uterine cavity
2. Uterine-distending gas: The ideal gas used as distending
Pain after examination Relatively Few
medium should be highly soluble, non-flammable, non- strong
explosive, easy to be absorbed and have no adverse reac- Distention equipment Necessary Not
tion. CO2 is a natural gas inside human body and can be necessary
quickly absorbed after being insufflated. Due to its high Gas embolism Possible Impossible
viscosity, CO2 is not likely to cause gas embolism after Floor contamination No Often
entering the blood. Furthermore, it does not cause any
damage to the equipment, is effective in distending the
cavity and does not produce any allergic reaction. The in mucus secretion; (3) it can be dangerous if improperly
refractive index of CO2 is 1.00. Compared with other used. If the distending pressure is too high, the chances of
media, it has a relatively large field of view and high defi- CO2 entering the blood vessels would increase, which lead to
nition. All of these make it the most ideal uterine distend- potential dangers including acidosis, arrhythmia, heart fail-
ing gas. ure, and gas embolism, and is even life-threatening in severe
cases.
The shortcomings of CO2 as a distention medium include: CO2 is a kind of excellent uterine distending medium,
(1) A special insufflating machine is needed, which is not as especially for diagnostic hysteroscopy or hysteroscopy with-
simple and convenient as that required for fluid distention out intrauterine operation. The field of view is especially
medium; (2) it may cause intrauterine bubbles or an increase clear with the use of gas insufflation. However, in the imple-
mentation of hysteroscopic operation, gas medium is not
very satisfactory. Intraoperative bleeding and smoke or bub-
ble produced by cauterized tissue make the field of view
blurred, which hinders the accomplishment of the operation.
Therefore, gas distending medium is rarely used in operative
hysteroscopy.
A comparison of distention media between CO2 and fluid
is made in Table 8.1.
8.1.5 Timing of Hysteroscopy
Generally, the ideal time for doing hysteroscopy is within

5 days after menstruation except for special conditions.
During this early proliferative phase, the endometrium is thin
with less mucus and not easy to bleed, so the intrauterine
lesions are more easily seen, which makes a satisfactory
Fig. 8.1 CO2 insufflator observation. For the patients with irregular bleeding, hyster-
oscopy can be done at any time after the bleeding has 8.1.7 Procedures of Hysteroscopy
stopped. If hysteroscopy is necessary to be done during
uterine bleeding period, it can be performed after administra- 8.1.7.1 Preparation Before Hysteroscopy
tion of antibiotics as appropriate. 1. Before hysteroscopy, the bladder is emptied, the patient is
examined to determine the position and size of the uterus.
If the procedure of hysteroscopy needs to be combined
8.1.6 Anesthesia and Analgesia with ultrasonography, the bladder should be kept moder-
in Hysteroscopy ately full.
2. A lithotomy position is taken, and vulvo-vagina is steril-
In order to reduce the intraoperative reaction, analgesics and ized with 0.25% or 0.5% iodophor. If intrauterine mucus
tranquilizers or intramuscular injection of atropine can be is too much and difficult to be removed, a 2 mL syringe
given preoperatively. It is also possible not to use anesthesia can be used to suck it out so as not to disturb the hystero-
in patients with relaxed cervical canal or when a flexible hys- scopic vision.
teroscope is applied. The commonly used analgesia and 3. The air inside the inflow pipe and between the sheath and
anesthesia methods are as follows. the scope must be emptied before insertion of the hystero-
scope. The fluid distention pressure is set at 80–100 mmHg
8.1.6.1 Indomethacin Suppository (10–13 kPa) and the flow rate is at 200–300 mL/min,
Normally, indomethacin suppository of 50–100 mg can be while the pressure of CO2 uterine distension is
inserted deep into the rectum 20 min before examination. 60–80 mmHg (about 10 kPa) and the flow rate is
Indomethacin could inhibit the synthesis and the release of 20–30 mL/min.
prostaglandin, and eliminate the sensitizing effect of pain 4. During the operation, noninvasive technique should be
fibers, so it has a good analgesic effect. Its plasma half-life is used as much as possible, including not using a specu-
20 min, thus the duration of analgesia is not long. Therefore lum, neither clamping or dilating the cervix, not sounding
it is appropriate for minor operations in the uterine cavity the uterus, and performing low pressure distension of
and the patients can leave the hospital quickly after uterine cavity, etc.
operation.
8.1.7.2 Procedures
8.1.6.2 Kaflan
Kaflan of 25–50 mg may be taken orally 30 min before Fiber (Flexible) Hysteroscopy
examination. 1. Control of the operating lever results in the up and down
movement of the objective lens. The tip of the hystero-
8.1.6.3 Paracervical Nerve Block scope is inserted through the cervical os under the direct
1% procaine of 5–10 mL or 0.5% lidocaine of 5–10 mL can vision and is guided by the flushing of distention fluid,
be injected into both sides of cervix, and the injection can which permits a comprehensive observation of cervical
only be administered if blood cannot be aspirated from the canal (Fig. 8.2a, b). Then the hysteroscope is introduced
injection needle. into the cavity and the direction of its tip is regulated by
rotating the scope or moving the lever, so observations of
8.1.6.4 Surface Anesthesia of Cervical Mucosa the cavity can be achieved sequentially, which include
It is done by inserting a cotton swab which had been dipped anterior wall, left cornua, left tubal orifice, posterior wall,
in the 2% lidocaine solution into the cervical canal up to the right cornua, right tubal orifice, and then fundus. When
level of the internal os for 1 min. retracting the scope after inspecting the cavity, the cervi-
cal canal should be carefully observed again as this part is
8.1.6.5 Endometrial Spraying Anesthesia difficult to expand and easy to be misdiagnosed.
1% lidocaine of 5 mL or 0.25% bupivacaine of 8 mL can be 2. If insertion of telescope into the uterine cavity meets
sprayed on the surface of endometrium through a special resistance, the pressure of the distending fluid can be
lumen injector, and the procedure could be done 5 min later. increased so that the tip of the hysteroscope is pushed
along with the water flow. If still unsuccessful, the inser-
8.1.6.6 Intravenous Anesthesia tion direction could be explored with a uterine probe with
Propofol or ketamine can be given via intravenous the cervix held with cervical forceps. When the probe
injection. could be introduced through the cervical canal but the
78 E. Xia and D. Yu
a b
Fig. 8.2 (a, b) Observation of the cervical canal with fiber hysteroscope
Rigid Hysteroscopy
1. It is mainly used when a more detailed observation of
intrauterine lesions, a bigger uterine cavity, and larger or
more complicated intrauterine lesions are needed.
2. The scopes of modern rigid hysteroscope are 12° or 30°
for oblique lens, so when the telescope is pushed forward
via the cervix, it should be rotated and the observation
should be done as well. After inserting the telescope into
the uterine cavity, the scope should be turned over, aim-
ing the oblique lens at the target to conduct the observa-
tion. For example, when the objective lens has reached
the uterine fundus, aiming oblique lens at the left side, the
left uterine cornua and tubal orifice can be observed, then
continue to rotate the scope mandrel 90° clockwise, the
uterine posterior wall maybe observed, and by analogy,
the observation sequence is the same with the
fiberscope.
3. The outer diameter of a rigid hysteroscope is larger,
therefore it is often necessary to do the cervical dilatation
and anesthesia to apply this noninvasive technique,
Fig. 8.3 The optical fibers of the hysteroscope are broken, and little excluding the conditions of chronic uterine bleeding or
black dots appear on the screen. (This is of a menopausal woman whose some major intrauterine space-occupying lesions, in
removal of IUD was not successful. Under hysteroscope, the residual which the cervical canal is relatively relaxed.
IUD is seen embedded in the right uterine wall)
Comparison Between Fiber Hysteroscopy and Rigid

internal os was seen to be narrow under hysteroscope, a Hysteroscopy
cervix dilator could be used to dilate it slightly. Be sure Unfried et al. made a comparison of imaging properties and
not to push forward the hysteroscope by force, otherwise the patient’s acceptance between fiber hysteroscopy and
the glass optical fibers inside the telescope might break, rigid hysteroscopy using a grading system. The results
resulting in blurred images and little dots appearing on showed that during the introduction and the examination
the screen. (Fig. 8.3). using rigid hysteroscope, the discomforts were significantly
greater than those of fiber hysteroscope (P = 0.003 and 8.1.8.1 Indications for Hysteroscopy Combined
P < 0.001 respectively), but the imaging properties were far with Ultrasonography
better (P < 0.001) and the duration of operations was signifi- 1. Anybody with indications for hysteroscopy.
cantly shorter (P = 0.003). Therefore it was concluded that 2. Patients who have pelvic masses with which the relation-
fiber hysteroscope seemed to cause less pain and was pre- ship of the uterus need to be determined.
ferred to be applied in outpatient setting. Nevertheless, rigid 3. The operation methods of uterine myomas are to be
hysteroscope could provide good imaging quality, short pro- decided.
cedure, a higher success rate and a lower cost.
8.1.8.2 Procedures for Hysteroscopy Combined
“No Touch” Technique with Ultrasonography
“No touch” hysteroscopy techniques, means the procedure 1. The bladder should be moderately filled so that the uter-
does not use speculum, not clamp the cervix, not dilate the ine fundus could be seen by ultrasonography.
cervical canal, not sound the uterine cavity, not need anes- 2. Before the start of hysteroscopy, a transabdominal ultra-
thesia, use the miniature instruments, and use low pressure to sonography should be first performed in order to detect
distend the cavity, thus it could be performed in an outpatient size and position of the uterus, thickness of the uterine
office. If the surgeon is quite experienced in discerning the wall, location and thickness of the endometrium, any
lesions under the hysteroscope, treatment and surgery could dents at the fundus, any malformation of the uterus, any
be continued. This “no touch” technique is called vagino- myomas, size, number and location of myoma, and the
scope, which needs a disinfected saline soaked gauze pad to state of the adnexa.
cover the vulva so as to prevent the leakage of distending 3. The hysteroscope is inserted along with the orientation of
medium from the vulva. It uses mini hysteroscope and is the uterine cavity under the guidance of ultrasonography.
applicable to young girls, unmarried women, women with While the uterine cavity is examined by hysteroscopy,
intact hymen, postmenopausal women, and those with vagi- abdominal ultrasound probe should be used to do hori-
nal and cervical stenosis. Bettocchi reported his experience zontal and vertical scanning up over the symphysis pubica
of vaginoscopy in 9093 cases during 10 years, all of them and make the full range of observation, taking the intra-
were successful with a satisfactory rate of almost 100%. uterine distention fluid and hysteroscope as the reference
object. If the fallopian tubes are patent, sometimes ultra-
sound scan images with water flowing through the tubes
8.1.8 Hysteroscopy Combined or over the fimbria could be seen. While the telescope is
with Ultrasonography retracted, attention should be paid to the sonographic
changes before and after the uterine distention and
The joint use of hysteroscopy and ultrasonography has made whether there is any uterine distention medium going into
these two advanced diagnostic techniques complementary to the uterine wall.
each other. It has altered the limitations of hysteroscopy for
simple diagnosis of intrauterine lesions and the limitations of 8.1.8.3 Abnormal Findings in Hysteroscopy
ultrasonography for simple diagnosis of lesions within or Combined with Ultrasonography
outside the uterine wall. It also has solved the problems of no
access to the relationship between the submucous myoma Intrauterine Lesions
and myometrial wall by hysteroscopy, and no way to detect 1. Uterine malformation: After the uterine cavity is dis-
the intrauterine space-occupying lesions smaller than tended adequately by the distention medium, ultrasono-
1–2 mm and to locate the submucous leiomyoma by only graphic imaging can display whether there is a dent in the
ultrasonography. The patient’s conditions of the uterine cav- contour of the uterine fundus, whether there is a septum
ity, uterine wall and pelvic cavity can be determined imme- at the fundus of the cavity, and its length, width, and
diately, comprehensively and accurately at one combined thickness, etc. Ultrasonography with high resolution can
examination. The joint inspection provides reliable informa- also show the myometrium within the septum, accurately
tion for diagnosis, expands the indications for hysteroscopy establishing the diagnosis of uterine septum.
and ultrasonography, and establishes new ways of rapid and 2. Intrauterine hematocele: Hysteroscopy can only detect
accurate diagnosis of gynecologic disorders. the intrauterine adhesion but cannot view the conditions
80 E. Xia and D. Yu
above the adhesive band, while the joint inspection can 1. Endometrium: It can be normal endometrium in men-
view simultaneously the location, extent, single cavity or strual cycles such as menstruation, proliferative phase
multi-cavities of intrauterine hematocele induced by and secretory phase, and atrophic or hyperplastic
adhesions. endometrium.
3. Intrauterine foreign body: The joint inspection can accu- 2. Protrusion of the endometrium: It includes endometrial
rately locate the foreign bodies, such as an IUD which is polyps, thickened endometrium, and polypoid, papillary,
totally embedded in the uterine wall or covered by nodular, hemispherical and spherical protrusions of the
endometrium. endometrium (Fig. 8.4).
3. Endometrial glandular opening: It can be presented as
Lesions on the Uterine Wall or Outside the Uterus punctiform, rotiform, and tubular (Fig. 8.5).
1. Intramural myoma: The joint inspection would combine
the intrauterine morphological changes detected by hys-
teroscopy with the location, size, and protruding degree
of the intramural myoma shown by ultrasonography,
through which the inward-protruding intramural myoma
is accurately located.
2. Adenomyosis: During the joint inspections, if the
opening of ectopic glands of adenomyosis originates
from the uterine cavity, the uterine distention medium
can flow into the uterine wall thus the area of lesion is
shown as inhomogeneous cloudy strong echoes on the
ultrasonogram.
3. Subserous myoma and adnexal masses: The joint inspec-
tion can observe clearly the relationship between them
and the uterus or uterine cavity.
8.1.9 A Normal Uterus Under Hysteroscopy
8.1.9.1 Various Images Seen by Hysteroscopy

Except for the especially obvious conditions, judgment and
histopathologic examination are still needed in deciding
whether the observed target is normal or not. Fig. 8.5 Endometrial glandular opening
Fig. 8.4 Protrusions of

endometrium (the figure was
kindly provided by Dr.
Takashima Hideyo)
Thickened
Endometrial polyps Hemisphere or globular
polypoid endometrium
Small polypoid Large polypoid

Nodular or rock-like
or finger-like or mushroom-like
Fig. 8.6 Normal or benign

blood vessels. (The figure was
Takashima Hideyo)
capillary network small blood dendritic vascular flattened shape

vessels vascular
Fig. 8.7 Atypical blood

vessels. (This figure was
Takashima Hideyo)
narrowed interrupted crooked snake-like lightening-shaped
venous
aneurysm engorged papillary frogspawn-like
4. Endometrial surface: It can be smooth, rough or uneven. above-mentioned vessels and vascular engorgement are
5. Transparency: It includes transparent, translucent or often seen in malignant tumor. In addition, the main fea-
opaque. ture of the papillary adenocarcinoma is that the central
6. Color: The endometrium can be white, gray-white, blood vessel can be seen in its long and short papillae.
yellow-white, brown, light red, and red.
7. Texture: The endometrium can be hard, soft, and 8.1.9.2 Normal Morphology of the Uterine Cavity
fragile. Viewed by Hysteroscopy
8. Necrosis: The endometrium may develop necrosis with
punctiform, patchy, and lamellar features. Cervical Canal
9. Normal blood vessels or benign blood vessels: It can be It is a circular or oval-shaped tube, and its shape may change
divided into the capillary network, small blood vessels, with the degree of uterine distention. The mucosa is pale red,
and dendritic vascular and flattened shape of vessels whitened or red, with more vertical and horizontal folds,
(Fig. 8.6). The capillary network can often be seen on which are significantly different from the uterine endome-
the normal endometrium and sometimes the small blood trium, and typical palm-like folds are occasionally seen
vessels and other vessels shaped like willow branch are (Fig. 8.8). The internal orifice is mostly round or oval, with
also benign blood vessels. Flattened shape of wide ves- its edge being tidy, smooth, and slightly irregular occasion-
sels can be seen over the submucosal myoma. ally. The internal orifice tilts forward or backward in those
10. Atypical vessels: Atypical vessels are mainly vessels uteri with obvious anteflexion or retroflexion. Compared
which are expanded and run irregularly (Fig. 8.7). The lat- with the endometrium, cervical mucosa is a little pale, so
ter refers to the vessels which appear to be partly narrow, many intrauterine interventions such as abortion, curettage,
run intermittently or with interruption, bending abruptly, placement or removal of IUD, and D&C can easily cause
or be snake-like or lightning-shaped winding. All the injuries and lead to adhesions of cervical canal.
82 E. Xia and D. Yu
trudes toward the uterine cavity so as to make both uterine

cornua appear deeper. The color, thickness, and wrinkles of
the endometrium vary with the menstrual cycle (Fig. 8.10a–d).
Endometrium
Its morphology varies with the age and menstrual cycle of
the patient.
Endometrium of Women in Reproductive Age

1. Endometrium in repair phase: It generally refers to the
fifth to sixth days of menstruation, during which the
entire uterine cavity is covered by the new epithelium
with the thickness of 0.5–0.9 mm. The endometrium
appears to be smooth, yellow-red, with rare vascular
veins, scattered bleeding spots and unclear glandular
openings (Fig. 8.11).
2. Endometrium in the early and middle proliferative phase:
Its thickness is 2–5 mm, and the endometrium gradually
turns into a red color, more wrinkled, and uneven. The
glandular openings become clearer and are distributed
equally with the endometrium being like a strawberry
(Fig. 8.12a, b).
Fig. 8.8 Normal cervical canal 3. Endometrium in late proliferative and early secretory
phase: It is 2–3 days before and after ovulation. The
endometrium is thickening and swelling, being light
yellow-red with translucent polypoid protrusions. The
subepithelial vessels might be visible. The glandular
openings can be unclear, wavy, and particularly evidently
concave (Fig. 8.13a–c).
4. Endometrium in secretory phase: The endometrium is
thickening to 7–8 mm and is undulating. Due to the inter-
stitial edema, the endometrium is yellowish-white or
yellowish-red translucent with hemispherical or polypoid
protrusions, with clear capillary network, and the white
punctiform glandular openings are not obvious or even
almost undistinguishable (Fig. 8.14a, b).
5. Premenstrual endometrium: Interstitial edema subsides,
the endometrium becomes thinner again, and there are
more small wrinkles on its surface, with scattered red
plaque hematoma underlying the endometrium, which is
fragile and easy to bleed (Fig. 8.15).
6. Menstrual endometrium: The endometrium is shed,
accompanied by punctiform bleeding spots and moss-like
pale stripped surface, and coarse vessels and glands
Fig. 8.9 The uterine fundus is flattened when it is well distended stump are visible (Fig. 8.16a, b).
Endometrium of Women in Postmenopause

Uterine Cavity The endometrium appears atrophic and becomes thinner,
With an ideal uterine distention, the uterine fundus is flattened smooth, yellow-white and opaque, and ecchymosis are often
(Fig. 8.9), but sometimes it is slightly arc-shaped and pro- visible (Fig. 8.17).
a b
c d
Fig. 8.10 (a–c) Normal uterine cavity. (d) Normal uterine cavity (CO2 uterine-distension)
84 E. Xia and D. Yu
Uterine Cornua and Fallopian Tubal Orifice occasionally like star or crescent. Sometimes it can also be
The uterine cornua present as deep and dark funnels before seen to shrink into the shape of a gap (Fig. 8.21). If the tube
the uterine cavity unfolds (Fig. 8.18a, b), while the fallopian is patent, the uterine distending fluid could be seen to flow
tubal orifice can be seen on top of or at the inner side of the into the fallopian tubal ostia.
top of the cornua after the cavity totally unfolds (Fig. 8.19a–
d). The tubal orifices are mostly round or oval (Fig. 8.20), Other Intrauterine Findings
1. Bleeding: Slices, streaks, and clots of blood may adhere to
the endometrial surface or be suspending in the uterine cav-
ity, the color of which varies with the length of bleeding
time with different colors like bright red, dark red, violet-
red, and purple-black, and all of which can shift with the
flow of distending fluid. Hemorrhagic spots or hemorrhagic
marks under the endometrium may be scattered or fused
together into patches, being red or dull red hemorrhagic foci
with their surfaces covered by the endometrium, so they do
not shift with the flow of the distending fluid. If small veins
or blood capillary actively bleed, the blood can be seen ooz-
ing out slowly. Arteriolar bleeding is associated with pulsa-
tion. If there is heavy bleeding, the blood will mix with the
distending fluid, resulting in a blurred red vision.
2. Mucus: It is white flocculent, flowing and deforming with
the distending fluid, and sometimes can also be attached
to the surface of the endometrium and is difficult to dis-
tinguish from the endometrial debris.
3. Endometrial fragments: They are partly attached to the
uterine wall, partly hang down in the uterine cavity, with
the color of pale or light red, and their shapes are more
rigid in distending fluid than the mucus. It can be shaken
Fig. 8.11 Endometrium in repair phase but does not shift.
a b
Fig. 8.12 (a) Endometrium in early proliferative phase. (b) Endometrium in middle proliferative phase
a b
Fig. 8.13 (a) Endometrium on the 12th day in a menstrual cycle. (b) Endometrium in early secretory phase. (c) Endometrium in early secretory
phase
86 E. Xia and D. Yu
a b
Fig. 8.14 (a, b) Endometrium in secretory phase
4. Bubbles: When the air in inlet pipes is not totally emp-

tied, it would flow into the uterine cavity and gather at the
anterior wall or the fundus of the uterus in the forms of
microvesicles.
8.1.10 Abnormal Findings Under

Hysteroscope
8.1.10.1 Submucosal Myoma

Submucosal myoma is round or oval in appearance and its
surface is white, smooth, and shiny, on which relatively thick
and dendritic vascular or vascular network running over its
surface is also visible (Fig. 8.22a, b). When the endometrium
on its surface is thickening, it is usually difficult to be distin-
guished from the endometrial polyps. In this condition, the
tip of the hysteroscope can be penetrated into this thickened
endometrium so that the white myoma nodules behind it
could be visible. The thickness of the pedicle and the degree
of protrusion toward the cavity of the myoma should be
Fig. 8.15 Endometrium on the 27th day in a menstrual cycle
observed carefully.
a b
Fig. 8.16 (a, b) Endometrium on the first day of menstruation
According to the relationship between myomas and the

myometrium, Haarlem international hysteroscopy training
center in Netherlands classified the submucous myomas into
three types, which has been commonly applied clinically and
was described in detail in Chap. 9, Sect. 9.3.
1. Type 0 submucosal myoma: It is pedunculated and does

not extend into the myometrium. A typical image under
hysteroscope is a round or similar round mass, which pro-
trudes into the cavity (Fig. 8.22c).
2. Type I submucosal myoma: It is sessile and extends less
than 50% into the myometrium. A typical image under
hysteroscope is a hemispheric protrusion, which pro-
duces an acute angle between the myoma and the uterine
wall (Fig. 8.22d).
3. Type II submucosal myoma: It is sessile and extends
more than 50% into the myometrium. A typical image
under hysteroscope is a hemispheric or an arc-shaped
protrusion, which produces an obtuse angle between the
myoma and the uterine wall (Fig. 8.22e).
Fig. 8.17 Endometrium in postmenopause
88 E. Xia and D. Yu
a b
Fig. 8.18 (a) Left uterine cornu under hysteroscope. (b) Right uterine cornu under hysteroscope
a b
Fig. 8.19 (a–c) Fallopian tubal ostium under hysteroscope. (d) Fallopian tubal ostium under hysteroscope (Interstitial segment of fallopian tube
is visible)
c d
Fig. 8.19 (continued)
Fig. 8.21 Fallopian tubal ostium presents as a gap under

Fig. 8.20 Fallopian tubal ostium is oval-shaped under hysteroscope
hysteroscope
90 E. Xia and D. Yu
a b
c d
Fig. 8.22 (a) Submucosal myoma. (b) Multiple intrauterine myomas. (c) Submucosal myoma (type 0). (d) Submucosal myoma (type I). (e)
Submucosal myoma (type II)
e Septate uteri can be classified into complete and incom-

plete septate uteri. The intrauterine septum extending
from the fundus to midline of the cavity can be detected
under hysteroscopy. A complete septate uterus is defined
as a septum extending to the internal os or cervical canal,
which fully divides the uterine cavity from the fundus to
the level of the internal os (Fig. 8.24a). A partial or
incomplete septate uterus is defined as a septum not
reaching the internal os, which partly divides the uterine
cavity from the fundus to the cavity (Fig. 8.24b, c).
2. Bicornuate Uterus: A bicornuate uterus is developed by
incomplete fusion of the middle segment of the Müllerian
ducts, which forms the bifurcate abnormity in the upper
part and the fundus of the cavity. The bicornuate uterus
can be classified into complete and incomplete bicornuate
uteri, of which the concrete criteria are still disputed.
Observations under hysteroscope can discover that there
are various degrees of convexities of the fundus, the
midline septum is similar to that of septate uterus, and the
septum can extend to the upper, middle or lower part of
the cavity, internal cervical os, or even cervical canal
(Fig. 8.24d).
3. Unicornuate Uterus: Unicornuate uterus is caused by
8.1.10.2 Intrauterine Adhesions asymmetric development of two Müllerian ducts, with
Intrauterine adhesions are adhered tissues between anterior unilateral duct developing normally and the contralateral
and posterior walls, and mostly locate either in the center or duct absent or failing to form a cavity. Under hysteros-
at the margins of the cavity (Fig. 8.23a, b). The intrauterine copy, the cavity of a unicornuate uterus is long and nar-
adhesions can be classified into endometrial adhesions, row, and only unilateral tubal ostium can be seen.
fibromuscular adhesions, and connective tissue adhesions. Sometimes it does not communicate with the rudimentary
The surface of endometrial adhesions looks similar to the uterus (Fig. 8.24e).
surrounding endometrium, which is easy to be divided by 4. Robert Uterus: It was first reported by Robert in 1970 and
hysteroscope (Fig. 8.23c). Fibromuscular adhesions, being was named after him. In the stage of embryonic develop-
light red or yellowish-white, grid-shaped or ledge-shaped, is ment, the absorption of the septum is disturbed during the
covered by the endometrium, so it has smooth surface, is fusing process of the two Müllerian ducts. The septum
hard and tough, and is not easy to be divided but prone to remained is not in the midline but on one side of the cav-
uterine perforation (Fig. 8.23d). The connective tissue adhe- ity, which totally blocks it, leading to a blind cavity non-
sion is a kind of relatively coarse and scarred tissue with pale communicating with the vaginal or contralateral cavity.
white surface, which is not covered with endometrium Under hysteroscope, a long and narrow cavity and an
(Fig. 8.23e). It should usually be distinguished from the uter- ipsilateral tubal ostium can be seen (Fig. 8.24f).
ine septum if it is in the center of the uterine cavity. The 5. T-shaped Uterus: A T-shaped uterus is a developmental
extensive adhesions inside the uterine cavity cannot be com- anomaly of myometrial constriction bands formation
prehensively investigated by hysteroscopy, so other adjunc- which are caused by the influence of intrauterine expo-
tive investigations such as HSG are usually needed. sure of diethylstilbestrol (DES) or other hazardous fac-
tors for patients in fetal period. Under hysteroscope, the
8.1.10.3 Congenital Uterine Abnormalities whole cavity is T-shaped with the upper part narrow and
Congenital uterine abnormalities include malformations like the fundus arced, the smallest distance between the mid-
didelphic uterus, unicornuate uterus, bicornuate uterus, arcu- dle of the fundus and the lateral walls is less than 2 cm,
ate uterus, saddle form uterus, septate uterus, Robert uterus, and the myometrium of both lateral walls of middle and
infantile uterus, and T-shaped uterus, etc. lower cavity is thickened which leads to a tubular cavity
(Fig. 8.24g).
1. Septate Uterus: A uterine septum is formed by the distur- 6. Arcuate Uterus: The arcuate uterus is a form of uterine
bance of the absorption process of the midline septum anomaly that the intrauterine septum cannot be totally
during the fusing process of the two Müllerian ducts. absorbed after the fuse of the two Müllerian ducts, which
92 E. Xia and D. Yu
a b
c d
Fig. 8.23 (a) Intrauterine adhesions (central). (b) Intrauterine adhesions (marginal). (c) Intrauterine endometrial adhesions. (d) Intrauterine fibro-
muscular adhesions. (e) Intrauterine connective tissue adhesions
e leads to myometrial thickening and protruding of the fun-

dus but does not form a specific septum. Under
hysteroscopy, the fundus is wide and thick, and protrudes
to the cavity without any definite septum (Fig. 8.24h).
7. Saddle form Uterus: The saddle form uterus is a kind of
uterine anomaly that occurs when incomplete middle
segment fusion of the two Müllerian ducts forms
slightly external fundal indentation and internal fundal
protrusion. Similar to arcuate uterus, measurements
under 3-D ultrasonography indicate that, taking the
connecting line between bilateral tubal ostia as base
line, the vertical distance between the midpoint of the
fundal protrusion and the base line is ranged from 0.5
to1.5 cm.
8.1.10.4 Intrauterine Foreign Bodies

The intrauterine foreign bodies include intrauterine device
(IUD), fractured cervical dilators, residual fetal bone, and
embryonic remnants after induced labor in second trimester,
or residual silk thread after cesarean section. It is usually not
Fig. 8.23 (continued) difficult to diagnose according to the external appearance of
a b
Fig. 8.24 (a) Complete uterine septum. The long and narrow septum left cavity with its shape unicornual, and the left tubal ostium can be
extends to the internal cervical os. (b) Incomplete uterine septum. (c) seen. (g) T-shaped uterus. A narrow, cylindrically shaped uterus is seen
Incomplete uterine septum. (d) Bicornuate uterus. A wide and short with the upper part stenosis and middle and lower parts constriction. (h)
plate in uterine cavity is seen under hysteroscope. (e) Left unicornuate Arcuate uterus. The fundus is wide and thickened, and protrudes to the
uterus. A long and narrow cavity with a tubal ostium at its top is seen cavity without any definite septum under hysteroscope
under hysteroscope. (f) Left Robert uterus. The telescope goes into the
94 E. Xia and D. Yu
c d
e f

g h
various foreign bodies. Occasionally, misdiagnosis or missed tissues with a nodular or floccular shape, and the surface
diagnosis may occur when the foreign bodies are too small, white, yellow, or yellow-brown in color (Fig. 8.26c, d). In
or when they are hidden by intrauterine hemorrhage, mucus, addition, hysteroscopy can also discover the pregnancy in
endometrial debris or some lesions. a cesarean scar. Under hysteroscopy, the embryonic
materials are attached to the anterior scar at lower part of
1. Intrauterine contraceptive device (IUD): Diagnostic hys- the cavity, and protrude to the cavity. Its surface could be
teroscope can observe the location and integrity of IUD in white, light yellow or dark-red (Fig. 8.26e). When per-
uterine cavity. Normally, an IUD is located in the center forming a hysteroscopic examination, if the uterine cavity
of the cavity. If there are two arms, they should sit at two is normal, but the embryonic materials lie in the cervical
cornua. Hysteroscopic examination can discover IUDs canal with its color white, light yellow or dark-red, cervi-
which are displaced, partly remained after a failed cal pregnancy could be diagnosed (Fig. 8.26f).
removal, embedded in myometrium or on the surface of 3. Residual fetal bone and endometrial ossification: In
an occupying lesion, etc. (Fig. 8.25a–h). patients with remained fetal bone, yellow-white firm bony
2. Intrauterine embryonic materials: Hysteroscopic exami- tissues in uterine cavity can be observed under hysteros-
nation may observe the gestational sac, or discover resid- copy, with a rod-like, flat, or irregular shape (Fig. 8.26g). In
ual embryonic materials in uterine cavity such as delayed patients with endometrial ossification, sand-like rigid tis-
miscarriage, incomplete miscarriage, adherent placenta, sues can be detected scattering locally in the cavity under
and placenta accrete. Diagnosis can be achieved hystero- hysteroscopy, with varying sizes, colors, and shapes, and
scopically in cooperation with the histopathological the largest diameter 1–2 cm (Fig. 8.26h).
examination. Under hysteroscope, intrauterine gesta- 4. Other foreign body remnants: By hysteroscopic examina-
tional sac is an irregular mass with its surface full of ves- tion, fractured cervical dilators or Laminaria tent may be
sels and its color dark-red (Fig. 8.26a). Sometimes fetal detected in cervical canal or uterine cavity, or residual
pole and even fetus can be detected. When the pregnancy silk suture or suture knot can be observed in the anterior
is in one cornu, the cornu on this side is bulky and filled wall at the level of internal cervical os in patients with
with irregular embryonic materials (Fig. 8.26b). Usually, previous cesarean section, over which inflammatory tis-
the residual embryonic materials are irregular dark-red sues are adhered and wrapped (Fig. 8.26i).
96 E. Xia and D. Yu
a b
c d
Fig. 8.25 (a) T-shaped copper intrauterine device and tail string. (b) ring IUD is embedded in longitudinal adhesive band of uterine cavity.
Intrauterine device (metal single-ring). (c) Cooper-bearing 250 intra- (h) A metal single-ring IUD is embedded on the surface of myoma from
uterine device. (d) Intrauterine device (multiload). (e) Intrauterine anterior wall
device (Ota’s). (f) Intrauterine device (“Y” shape). (g) A metal single-
e f
g h
8.1.10.5 Endometrial Polyps submucous myomas (Fig. 8.27a, b). The gland of endome-
Endometrial polyps are benign nodules projecting from the trial polyps may be inactive, sometimes proliferative or
surface of endometrium, which is made up of endometrium, secretory. In addition, varied metaplasia or other kinds of
glands, and stroma, and generally contains some fibrous tis- hyperplasia may also occur. Sometimes cancer or other
sues. It has a slender cone or oval-shaped appearance and a malignancies may develop from the polyps. According to
smooth surface, on which there are often blood vessels. It Kurman’s report, endometrial polyps can be classified into
may be single or multiple, large, or small. The large one may hyperlastic, atrophic, functional, mixed endometrial-
prolapse out of the external orifice of cervix and the small endocervical, adenomyoma, and atypical polypoid adeno-
one can only be seen with a microscope. It may appear to be myoma. Takashima Hideyo divided them into four types,
ball-shaped occasionally and must be differentiated from which is more practical clinically.
98 E. Xia and D. Yu
a b
c d
Fig. 8.26 (a) Intrauterine embryonic materials (on the 44th day of pregnancy. (e) Pregnancy in cesarean scar. The irregular embryonic
pregnancy). By hysteroscopy, a mass is shown on anterior wall, with materials lying in the lower anterior wall protrude to the cavity with a
plenty of vessels on its surface. (b) Left cornual pregnancy. Irregular dark-red surface. (f) A cervical pregnancy. The irregular embryonic
embryonic materials are identified in the left cornu of the cavity, with a materials are detected in cervical canal with dark-red color. (g)
diameter of 1.5 cm. (c) Residual embryonic materials are detected in Intrauterine fetal bone remnant. A bony tissue in uterine cavity is seen
uterine cavity under hysteroscope half a year after artificial abortion. under hysteroscopy, which is flat, yellow-white and rigid. (h)
(d) Bleeding, gestational sac, and decidual tissues are visible under hys- Endometrial ossification. Sand-like small nodules are scattered in the
teroscope after two failed suction aspirations in a patient who had cavity under hysteroscope, which are firm and white. (i) Fractured sili-
amenorrhea for 2 months and failure in medicine abortion for early cone dilator. A translucent light brown tent is detected in the cavity
e f
g h

100 E. Xia and D. Yu
i 1. Hyperplastic polyps: They are common in patients of age

40–50. The polyps have much more hyperplasia of glands,
with smooth surface, no atypical vessels, and scattered
glandular openings (Fig. 8.28a). They are inactive to pro-
gestogen with their tips usually flushing and bleeding.
2. Functional polyps: The glands present the same changes
as those in menstrual cycle, so the color and the state are
the same as that of surrounding endometrium. During the
proliferative phase, the endometrium is light red or ash
gray with most glandular openings visible. During secre-
tory phase, the polyps are edematous, pale yellow or grey
white, glandular openings are not clear with the subepi-
thelial vessels visible (Fig. 8.28b).
3. Atrophic polyp: After the menopause, hyperplastic or
functional polyps degenerate, and show similar changes
to the surrounding endometrium. Histologic features are
atrophic glandular epithelium, dilatated gland duct, and
fibrosed interstitial substance. The light reddish white
polyps with smooth surface can be seen under hystero-
scope, vascular dilatation is not obvious, but sometimes
scattered translucent vesicles and dendritic dilated blood
Fig. 8.26 (continued) vessels are also visible (Fig. 8.28c).
a b
Fig. 8.27 (a) Endometrial polyp. (b) Multiple endometrial polyps

a b
c d
Fig. 8.28 Endometrial polyps. (a) An endometrial hyperplastic polyp. (b) Endometrial functional polyps. (c) An endometrial atrophic polyp. (d)
An adenomatous polyp
4. Adenomatous polyps: Adenomatous polyp is one kind of 8.1.10.6 Endometrial Hyperplasia

endometriosis, with endometrium on its surface, and a Endometrial hyperplasia (Fig. 8.29a–d) refers to the exces-
muscular fiber mass mixing with endometrium inside. It sive proliferation of the endometrial glands without atypical
has the same appearance as submucous myoma, so the cells. The hyperplasia of glands is sometimes focal
histopathological examination is often needed for the dif- (Fig. 8.30a–c), sometimes diffuse (Fig. 8.31a–c). Endometrial
ferentiating diagnosis (Fig. 8.28d). hyperplasia can be classified into the following two types.
a b
c d
Fig. 8.29 (a) Endometrial hyperplasia. The endometrium is grey, and plex hyperplasia. Glandular openings with different sizes and uneven
presents as tiny, coarse and irregular protrusions. (b) Endometrial com- distributions can be seen on its surface. (d) Endometrial complex
plex hyperplasia. The external appearance presents as yellowish-white hyperplasia, sampling for examination with biopsy forceps
or red opaque polypoid or lichenoid protrusions. (c) Endometrial com-
a b
Fig. 8.30 (a) Focal hyperplasia of endometrial glands (far view). (b) Focal hyperplasia of endometrial glands (close view). (c) Secretory endo-
metrium and focal hyperplasia of endometrial glands in posterior wall
a b
Fig. 8.31 (a–c) Diffuse hyperplasia of endometrial glands
1. Simple hyperplasia: It is equivalent to cystic endometrial small round translucent vesicles visible, presenting various
hyperplasia according to the old classification, and it usually colors from red to pale grey. The blood vessels on its surface
has glands expansion and stromal hyperplasia, so it shows are smaller and appear regular (Fig. 8.32a–d).
mild irregular morphology. Multiple small polyps or solitary 2. Complex hyperplasia: It is equal to the adenomatous
large polyp and mossy uplift are visible under hysteroscope. endometrial hyperplasia according to the old classifica-
The surface of the endometrium is smooth and opaque, with tion, with obvious glands hyperplasia, loss of gland polar-
a b
c d
Fig. 8.32 (a) Polypoid endometrium, with polypoid and moss-like blood vessels running regularly on its surface. (c) with the surface
protrusions of endometrium visible on both anterior and posterior walls smooth and opaque, and tiny blood vessels running regularly. (d) with
in uterine cavity. Simple hyperplasia of endometrium. (b) with tiny irregular polypoid protrusions
ity, and irregular alignment. The appearance consists of 8.1.10.7 Atypical Endometrial Hyperplasia
yellowish white or red opaque polypoid or moss-like pro- Atypical endometrial hyperplasia refers to excessive hyper-
trusions, with atypical vessels and various sizes of plasia of endometrial glands containing heterocyst. Polypoid
unevenly distributed glandular openings visible on the or moss-like protrusions, with yellowish white or ash grey
surface (Fig. 8.33a–i). opaque surface and atypical vessels, are visible under the
a b
c d
Fig. 8.33 Complex hyperplasia of endometrium. (a) Irregular polyps ible. (f) With atypical blood vessels and bleeding points visible. (g)
and moss-like protrusions are visible, with blood vessels enlarged and With focal and irregular protrusions on the posterior wall and its surface
running in a disorderly fashion. (b) Presenting with white opaque pol- appears yellowish-white. (h) With coarse surface, irregular morphology
ypoid protrusions. Focal complex hyperplasia of endometrium. (c) With and a little enlarged blood vessels. (i) With several polypoid or moss-
atypical blood vessels and bleeding points visible. (d) With enlarged like protrusions on the posterior wall and atypical blood vessels on its
and irregular blood vessels visible. (e) With atypical blood vessels vis- surface
e f
g h

hysteroscope (Fig. 8.34a–d). It is usually difficult to be dif-

i
ferentiated from endometrial carcinoma by hysteroscopy
only.
8.1.10.8 Endometrial Carcinoma

Endometrial carcinoma (Figs. 8.35 and 8.36a–d) can be clas-
sified into localized and diffuse types according to its mor-
phology and extent. It can also be separated into endogenic
and exogenic varieties according to the developmental orien-
tation. The exogenic lesions develop toward the uterine cav-
ity with a higher incidence, and they often have special
appearances, most of which can be diagnosed under hystero-
scope. However, the diagnosis of an endogenic lesion is
more difficult. There are three hysteroscopic findings,
namely papillary, nodular, and polypoid protrusions, which
can appear separately or as a mixture. When the pathology
progresses, a focal carcinoma may be extended to diffused
lesions, and extensive necrosis, infection and ulcers may
develop, which can be used to assess the depth of myome-
trial infiltration.
a b
Fig. 8.34 Atypical endometrial hyperplasia. (a) With grey-colored scope. (d) A localized area over the posterior wall is congested, with
moss-like protrusions on the posterior wall. (b) With atypical vessels blood vessels enlarged and running irregularly
visible. (c) With atypical vessels and bleeding visible under hystero-
c d
Fig. 8.35 Endometrial

carcinoma Localized Type Diffused Type
papillary protrusion polypoid protrusion endogenous
extensive necrosis, infection and ulcer exogenic
Hysteroscopic Findings 2. Papillary protrusions (Fig. 8.39): They are made up of

1. Nodular protrusions (Figs. 8.37 and 8.38): They are the translucent villiform protrusions with central vessels. As
most common findings of endometrial carcinoma, with specific findings in well differentiated adenocarcinoma,
uneven nodular protrusions in appearance, and opaque the villiform protrusions are varied in length and often
yellowish-white or ash grey in color. On its surface the accompanied by white punctiform necrosis.
engorging blood vessels present irregular snake-like 3. Polypoid protrusion (Fig. 8.40a–c): It may be large or
winding, and white punctiform or maculosus necrosis is small, and appear to be an oval or sphere-shaped emi-
often visible. nence. The base may be thin or thick. There are no vessels
a b
c d
Fig. 8.36 (a–d) Endometrial carcinoma
visible on its surface or irregular expanded vessels visible make the diagnosis of cervical infiltration if there is only
occasionally. a single lesion in the cervical canal. In addition, endome-
4. Necrosis and ulcer: There are white punctiform or macu- trial cancer tissues may be hanging from the cavity into
losus necrosis tissues. Repeated inflammations, suppura- the cervical canal, which is non-infiltrative and must be
tion, and necrosis may lead to irregular and rough differentiated from invasion.
ulcer-like appearance.
5. Cervical canal infiltration: If the cancer tissues invading Keypoints of Diagnosis Under Hysteroscope
the cervix are closely related to the intrauterine foci, it The following findings may be indications for endometrial
can be classified as infiltrating carcinoma, which is stage carcinoma and so a biopsy specimen must be sent for histo-
II endometrial carcinoma. However, it is more difficult to pathological examination.
Fig. 8.37 Nodular protrusions of endometrial carcinoma
1. Translucent villiform protrusions with central vessels are

highly likely to be well-differentiated endometrial
adenocarcinoma.
2. There are atypical vessels and especially irregularly
expanded vessels (Fig. 8.41).
3. Nodular or polypoid eminences with a fragile texture.
4. There are white punctiform or maculosus necrosis
tissues.
Precautions During Hysteroscopy

Whether diagnostic hysteroscopy may cause metastasis of
cancer into the peritoneal cavity is always a problem worried
by hysteroscopic surgeons. In a large-scale investigation
conducted in Japan, the conclusion reached was that diag-
Fig. 8.38 Nodular protrusions of endometrial carcinoma nostic hysteroscopy did not affect the five-year survival rate.
Fig. 8.39 Papillary protrusions of endometrial carcinoma
But even so, the uterine distention pressure must be lowered Practicability of Hysteroscopy
to a minimum and the increase of pressure should be avoided 1. Sometimes endometrial carcinoma can be judged from
as much as possible. Moreover, resectoscope is sometimes the specific appearance of the eminence under
used to obtain a large volume of specimens for histopatho- hysteroscope.
logical examination, but there is also a possibility of pulmo- 2. The histopathological types or the degrees of histological
nary metastasis of cancer cells through blood vessels under differentiation can be inferred in some lesions.
high-pressure irrigation, so some people believe that it 3. After determining the location of the foci, a biopsy should
should be regarded as an absolute contraindication. be done under direct vision, thus even small lesions can
Fig. 8.40 (a) Large polypoid protrusions of endometrial carcinoma. (b) Small polypoid protrusions of endometrial carcinoma. (c) Diffused pol-
ypoid endometrial carcinoma

c 8.1.10.9 Intrauterine Inflammatory Disease

1. Acute endometritis: It is a contraindication for hysteros-
copy. Cravello reported endometrial edema and bleeding
covered by abnormal mucus under hysteroscope in a
patient with acute endometritis.
2. Chronic nonspecific endometritis: It is mostly common in
post-menopausal women with the endometrium conges-
tion being crimson or ignitus. Cravello reported that the
endometrium was “strawberry-like” with white points in
its center. The subepithelial vascular network becomes
intensified and increased, with slightly wrinkled surface
(Fig. 8.42a–c). The endometrium around the intrauterine
lesions such as foreign body or cancer etc. is mostly
accompanied with chronic inflammation, presenting as
hyperemia (Fig. 8.43a–c), edema, exudation or even
necrosis.
3. Uterine empyema: The surface of uterine cavity is cov-
ered by a thick, brown, or yellow-green crust when pus
builds up, and dark red or brown-red inflamed granulo
endometrium with coarse surface exposed after flushing,
Fig. 8.40 (continued) which is usually associated with other intrauterine organic
lesions, such as endometrial carcinoma.
4. Endometrial tuberculosis: It manifests as uterine cavity
stenosis and irregularity, and the cavity is filled with yel-
lowish white or isabelline tissue unorderly and fragile
polypoid neoplasm, associated with bilateral uterine cor-
nua blockage (Fig. 8.44). For patients in more advanced
stages, the uterine cavity is seriously deformed and
adhered with quite firm scar tissues which are difficult to
be expanded and separated.
5. Granulomatous endometritis: Colgan et al. studied the
endometrial healing process after endometrial ablation
(EA). Among 19 cases who underwent EA, 15 cases were
treated for dysfunctional uterine bleeding (DUB), while
the other four had EA due to atypical hyperplasia revealed
during TCRE. The specimens of the uterus were obtained
from 1 to 48 months after EA and were sent for histo-
pathological examinations. Among six cases examined
within 3 months after ablation, myometrial necrosis, red
foreign body, granulomatous reaction, myometrial necro-
sis, thermal damage, and acute inflammation with vary-
ing degrees were found in five cases. Myometrial necrosis
Fig. 8.41 Thick and irregular blood vessels on the surface of was never exhibited in the specimens at 3–16 months
carcinoma after ablation of the remaining 13 cases. Persistent granu-
lomatous and/or foreign-body reaction were detected in
five cases. Obvious endometrial scarring were found in
be diagnosed correctly and a blind curettage can be nine cases. It was thought that the postoperative reactions
avoided. of EA should be recognized as granulomatous endometri-
4. Judging whether there is cancer infiltration within the tis. It was reported that a patient with postoperative gran-
cervical canal and staging for endometrial carcinoma. ulomatous endometritis had been cured by uterine
a b
Fig. 8.42 (a–c) Endometritis

a b
c d
Fig. 8.43 (a–c) Endometrial congestion

of thickened and uneven endometrium, distorted uterine

cavity, and obscure visualization.
8.1.12 Causes of and Solutions

to Hysteroscopic Failures
Sometimes hysteroscopy is not successful. Van Trotsenburg

et al. reported on 317 premenopausal patients who had out-
patient hysteroscopies due to abnormal uterine bleeding. The
procedures succeeded in 305 cases (96.2%), but the success
rate increased up to 98.9% when lidocaine spray was rou-
tinely used. Nagele et al. reported that the success rate of
outpatient hysteroscopy was 96.4%, while Unfried et al.
reported a success rate 87.5% with fiber hysteroscope and
100% with rigid hysteroscope. The causes for failure are as
follows:
1. Difficulty in insertion of the hysteroscope: If the cervix is

narrow, the Hegar dilator can be used to expand it under
Fig. 8.44 A narrow uterine cavity with endometrial tuberculosis the guidance of ultrasonography. If the flexion degree of
the uterus is too great and the dilating of the cervix is dif-
ficult, a fiber hysteroscope could be used instead.
curettage in the Hysteroscopy Center of Fuxing hospital, 2. Bubbles in the uterine cavity: The incompletely emptied
Capital Medical University. air in the irrigating tube or sheath of the hysteroscope
enters the uterine cavity and gathers beneath the anterior
8.1.10.10 Denomyosis wall or at uterine fundus in the form of microvesicles.
On the endometrial surface in cases with adenomyosis, ecto- The operators can adjust the uterus to the retroposition or
pic glandular openings are visualized as punctiform diver- move the telescope backward and forward quickly so as
ticula, small hematoceles are shown as purple-blue glandular to drive out air bubbles, although sometimes it is very dif-
openings or purple-blue points hidden underlying the ficult to take effect. Since all the air bubbles accumulate
mucosa. Sometimes thickened vessels with thin walls and beneath the anterior wall and at the uterine fundus, this
adhesive or scarring changes are visible in the uterine cavity area should be examined as early as possible during
(Fig. 8.45a–c). hysteroscopy.
3. Intrauterine blood clots or bleeding: For patients with
more bleeding, a rigid urethral catheter can be placed into
8.1.11 Principles of Endometrial Biopsy the uterine cavity, and normal saline may be injected
for Histopathologic Examination quickly so as to wash away the blood clots, and then a
During Hysteroscopy hysteroscope is inserted quickly to perform the examina-
tions. For patients with much more bleeding, the pressure
There are four principles: and/or flow rate of uterine distending fluid can also be
increased so as to wash out the blood clots and the blood.
1. As for a normal uterine cavity, especially in menopausal If the internal os is relaxed, a rigid urethral catheter can
women, sampling may not be needed. be placed beside the hysteroscope in order to accelerate
2. As for common benign lesions, uterine aspiration or ran- the circulation of uterine distending fluid so as to keep a
dom curettage of endometrium is suggested. clear vision. Spraying adrenaline into the uterine cavity
3. As for obviously focal lesions, hysteroscopic biopsy or has been reported to reduce bleeding.
target sampling for examination is suggested (Fig. 8.46). 4. Unclear visualization: It is mostly due to the inadequacy
4. As for obviously diffuse lesions, the whole functional of uterine distension which may be caused by a relaxed
layer of the endometrium should be resected with wire internal os and leakage of uterine distending fluid. In this
loop electrode for examination. Garuti et al. recom- condition, a bigger hysteroscope can be used instead, and
mended that endometrial sampling be obtained in cases clamping the cervical os with a cervical clamp or elevat-
a b
Fig. 8.45 (a) Ectopic glandular openings on the endometrium in a patient with adenomyosis. (b) Ectopic focus underlying the endometrium in a
patient with adenomyosis. (c) Intrauterine adhesions and scars in a patient with adenomyosis
ing the pressure and flow rate of distending fluid can be 8.1.13 Management After Hysteroscopy
applied. In some individual cases when the lens are
stained, 0.5% iodine or 95% ethyl alcohol can be used to During hysteroscopy, the patients may complain of lower
swab it. abdominal pain. Uterine distention with CO2 may cause
5. Intrauterine lesions such as endometrial hyperplasia, slight shoulder pain, which can be mostly relieved 1 h later.
uterine malformation or intrauterine adhesions, which There may be low-grade fever for several days post-operation
affect a full inspection of fallopian tubal ostia. A joint or small amount of bleeding within 1 week after the opera-
examination with ultrasonography may be helpful. tion. Therefore, sexual activity should be avoided for 2 weeks
6. If quite a large amount of fluid is injected, endometrium after the operation, and antibiotics should be used for pre-
edema may result, which may affect the observation. vention of infection when necessary, the underlying diseases
7. If a patient is too nervous, anesthesia may be needed. should also be treated.
pressure. (4) When there is heavier bleeding and/or

abdominal pain, Ultrasonography should be used to scan
the pelvic cavity comprehensively, and the operator
should note whether there is free fluid around the uterus,
and observe carefully whether the images under
hysteroscope are what it is in the uterine cavity to deter-
mine or exclude uterine perforation and formation of
false passage. Figure 8.47a–g are images when the hys-
teroscope is inserted into the right broad ligament during
hysteroscopy.
8.1.14.2 Bleeding
Generally, slight hemorrhage occurs after hysteroscopy,
which can be cleared within 1 week. No heavy bleeding has
ever been observed in patients who underwent diagnostic
hysteroscopy. Symptomatic treatment is needed for the
patients with more bleeding.
8.1.14.3 Infection
The occurrence of infection is quite rare. Franklin reported
Fig. 8.46 Localizing and sampling for examination with biopsy that its incidence was 0.2%, most of which was related with
forceps improper sterilization of instruments. Some sporadic cases
had previous chronic pelvic inflammatory disease. Therefore,
8.1.14 Prevention and Treatment case history should be queried in detail, and attention should
of Complications in Hysteroscopy be paid to whether there was pelvic tenderness and adnexal
thickening or not. If so, proper antibiotics should be admin-
Hysteroscopy is safe and reliable with relatively few compli- istered intraoperatively and postoperatively. Bracco et al.
cations, most of which can be prevented. studied the infectious complications after hysteroscopy.
Among 253 cases that were followed up for 20 days after
8.1.14.1 Damage procedures, bacteria from the cervical canal were detected in
1. Causes and symptoms: During the dilation of cervix and 35 cases and the positive rate decreased with age. Pelvic
insertion of the sheath of hysteroscope, cervical lacera- inflammatory disease was identified in two cases (0.79%)
tion and uterine perforation may occur, most of which are with Chlamydia trachomatis detected from the cervical canal
related to rough operation. The patients may have increase in both. The conclusion was that patients at higher risk of
vaginal bleeding and other symptoms like abdominal developing pelvic inflammatory disease following hysteros-
pain, but some patients may be asymptomatic. Once the copy were patients under 35 years of age, infertility and
sheath of hysteroscope is inserted through the internal os those with pelvic pain. Meae’s data indicated that application
of cervix, the occurrence of perforation will decrease. of hysteroscopy on patients suffering from salpingitis before
Excessive uterine-distending pressure may lead to rup- the examination may lead to severe pelvic infection. Severe
ture of fallopian tubes. postoperative infections had occurred in four cases following
2. Prevention measures: (1) Ultrasonography guidance: hysteroscopic examinations in the Hysteroscopic Center of
Insertion of the hysteroscope under Ultrasonography Fuxing Hospital, Capital Medical University, with the pro-
guidance may reduce or prevent the damages caused by cesses given in Table 8.2. Of them, the first case with previ-
incorrect direction of inserting. (2) Be alert to high-risk ous pelvic inflammatory disease had acute episode caused by
factors for uterine perforation, such as excessive uterine hysteroscopy, and antibiotics were administered preopera-
flexion, suspected carcinoma and tuberculosis, breast- tively and postoperatively. The second to forth cases were all
feeding or post-menopausal women. Cervical dilator may examined with fiber hysteroscope, which was disinfected
be inserted into the cervix or 200 μg misoprostol may be with 75% ethanol at that time and now it is disinfected with
placed in vagina 4 h before the examination to soften the Swashes immersion instead.
cervix and prevent damage. (3) The use of automatic
uterine-distention control device: The continuous disten- 8.1.14.4 Vaso-Vagal Syndrome
tion pressure should always be set below 100 mmHg to Dilation of cervix and distention of uterine cavity may lead
prevent rupture of fallopian tubes caused by excessive to increased tension of vagus nerve, and the same symptoms
a b
c d
Fig. 8.47 Perforation at left uterine isthmus with rigid hysteroscope. bleeding decreases and the base surface is clearly seen. (e) After the
(a) Diffuse effusion of blood is seen after inserting a 4.5 mm rigid hys- right-side cavity is washed thoroughly, yellow adipose tissues are visi-
teroscope. The uterine cavity mistakenly entered is actually the place ble. (f) After the hysteroscope is moved backward, the surface of cavity
between left parauterus and broad ligament. (b) After the flow rate of is seen to be blood-staining. (g) After the telescope is moved backward,
uterine-distending fluid is accelerated and the blood is washed out, pale the surface of cavity is blood-staining. Compressed by the telescope,
yellow adipose tissues can be seen in the posterior wall of the cavity. (c) there is no obvious bleeding in the left lower area, with pale yellow
Bleeding is visible from upper area of view with separation of tissues. appearance
(d) After washing with the uterine-distending fluid, the amount of
e f
of Vaso-Vagal Syndrome are as those in induced abortion. It 8.1.14.6 Gas Embolism

is quite rare and can be treated symptomatically. and Pneumoperitoneum
Air embolism may be caused when air in the inflow pipe is
8.1.14.5 Allergic Reaction not emptied completely during the use of fluid distention
Very few people are allergic to dextran, causing symptoms medium, or CO2 embolism can occur when CO2 is applied as
like rashes and asthma, etc., to whom Hyskon solution or distention medium. The manifestations include shortness of
sodium carboxymethyl cellulose cannot be applied. breath, chest distress and coughing, etc. The operation should
Table 8.2 The morbidity and treatment of infections in four cases following hysteroscopy
No. Clinical diagnosis Types of hysteroscope Clinical manifestations Treatment processes
1 DUB, PID history Rigid hysteroscope(immersion Fever, mass on right adnexa No improvement in response to
disinfection with swashes) on the third day conservative treatment. Right adnexa
removed by laparotomy. Chronic
inflammation of right fallopian tube with
tiny purulent foci, and right ovarian
chocolate cyst confirmed by
histopathological examination.
2 DUB Fiber hysteroscope High fever, lower abdominal Conservative treatment, cured by
(disinfection with 75% tenderness, rebound antibiotics.
ethanol) tenderness and increased
vaginal discharges on the
second day
3 DUB, adenomyoma Fiber hysteroscope High fever, lower abdominal No improvement in response to
(disinfection with 75% pain, enlarged uterus and conservative treatment. The uterine corpus
ethanol) obvious tenderness on the was removed by laparotomy.
second day Adenomyoma with local purulent foci in
the uterine wall was confirmed by
4 DUB, adenomyoma Fiber hysteroscope High fever, lower abdominal No improvement in response to
(disinfection with 75% pain, enlarged uterus and conservative treatment. The uterine corpus
ethanol) obvious tenderness on the was removed by laparotomy.
second day Adenomyoma with local purulent foci in
the uterine wall was confirmed by
be stopped immediately to avoid life-threatening risk. HSG could be confirmed by hysteroscopy. There were sev-
Pneumoperitoneum is resulted from too much absorption of eral reports comparing the diagnosis of intrauterine abnor-
CO2, may cause abdominal distention and shoulder pain, and malities by HSG and the confirmation by hysteroscopy
will disappear after CO2 is absorbed. (Table 8.3). As hysteroscopy can only inspect the uterine
cavity, but is not able to find out the conditions of the uterine
walls and the fallopian tubes, hysteroscopy cannot replace
8.1.15 Experiences and Evaluation HSG absolutely.
of Hysteroscopy
8.1.15.2 Comparisons of Hysteroscopy
Owing to the direct inspection of the uterine cavity with hys- and D&C
teroscope, most intrauterine diseases can now be diagnosed D&C is a blind operation, which solely relies on the sur-
accurately and quickly. It is estimated that use of hysteros- geon’s feeling and experience, so missed diagnosis is easy to
copy in patients with indications may increase the diagnostic happen. The intrauterine lesions, especially soft polyps,
rate of intrauterine abnormalities from 28.9% by other tradi- often cannot be scraped, and focal lesions cannot be located,
tional ways to 70%, among whom quite a few abnormalities which may lead to missed diagnosis. There had been reports
detected by hysteroscopy cannot be diagnosed by other tradi- that even when D&C was performed by experienced gyne-
tional ways. cologist, the residual rate of endometrium after curettage
reached up to 20–25%, while hysteroscopy was able to make
8.1.15.1 Comparisons of Hysteroscopy and HSG up for the inadequacies of curettage. Gebauer et al. reported
During X-ray radiographic study (HSG), false positive diag- the results of hysteroscopy and simple uterine curettage in 83
nosis may result from intrauterine small blood clots, mucus, patients. The indications for hysteroscopy were postmeno-
endometrial debris and insufficient contrast medium, etc. In pausal bleeding and/or abnormal endometrium detected by
addition, misdiagnosis may also be caused by technical fac- ultrasonography. Endometrial polyps were revealed in 51
tors, the choice of the contrast medium and differences in the patients by hysteroscopy and in 22 patients by simple curet-
interpretation of the images. According to statistics, only tage (43%). Epstein et al. studied postmenopausal women
43–68% of the patients who were found to be abnormal by with the thickness of endometrium ≥5 mm by TVS. By hys-
Table 8.3 Diagnosis of intrauterine abnormalities by HSG and hysteroscopy in published literatures
Percentage of cases confirmed by
Year Authors No of cases with abnormal HSG hysteroscopy (%)
1956 Norment 50 60
1957 Englund et al. 21 52
1970 Guerrero et al. 41 65
1973 Neuwirth and Levine 10 60
1973 Porto 76 5
1974 Porto 134 70
teroscopy or hysterectomy, intrauterine lesions were found women with abnormal uterine bleeding. Findings of 397
in 80% of the patients, among them, 98% of the lesions were patients were compared with histopathologic results. The
detected by hysteroscopy. In 87% of the women with focal sensitivity and the specificity for hysteroscopy were 92%
lesions in the uterine cavity, the lesions were not completely and 95%, with the positive and the negative likelihood ratios
removed by D&C. 58% of polyps, 50% of hyperplasia, 60% 18.4 and 0.08, respectively. Those for TVS were 67% and
of complex atypical hyperplasia, and 11% of endometrial 87%, with the positive and the negative ratios 5.15 and 0.38,
carcinoma were missed by D&C. Brooks reported that the respectively. Therefore, it was concluded that hysteroscopy
false-negative rate of D&C in women with AUB was 10–15% had the advantages of rapid diagnosis and well tolerated,
with the missed diagnosis of submucous myoma remarkably which was more accurate than TVS in detecting lesions in
high. Luo from China reported that about 35% area of uter- uterine cavity. Deckardt compared the examination results
ine cavity could not be scraped during the D&C procedure. with TVS, hysteroscopy, and D&C in 1286 perimenopausal
Therefore, it is believed that D&C should no longer play a and postmenopausal women with bleeding. Among 29 cases
significant role in the endoscopy era. Seamark even declared (2.26%) who were histopathologically diagnosed of endo-
its death. In some developed countries, there has already metrial carcinoma, the thickness of endometrium was
been trend of the hysteroscopy replacing blind dilatation and ≤5 mm in 2 cases (7.14%), and the diagnosis of endometrial
curettage. However, it still should be realized that hysteros- carcinoma by hysteroscopy was missed in 10 cases (34.5%).
copy also has limitations, as simple hysteroscopy alone may Therefore, in perimenopausal and postmenopausal women
also miss diagnosis such as hormone affected endometrium who were suspected of endometrial carcinoma, it could not
or atypical hyperplastic endometrium, the reason is that be reliably excluded by TVS or hysteroscopic examination
these changes may not have reached the identifiable degree alone.
with naked eyes. Therefore, hysteroscopy must be combined
with histopathological examination so as to improve the 8.1.15.4 Comparisons of Hysteroscopy
diagnosis. and Transvaginal Color Doppler
(TVCD)
8.1.15.3 Comparisons of Hysteroscopy Bidzinski et al. investigated the application of color flow
and Ultrasonography Doppler (CDF) and hysteroscopy to evaluate the endome-
In cases with uterine myomas suggested by ultrasonography, trium status in 33 patients who had endometrial cancer and
if the endometrial lining is obscure, it would be difficult to were treated by radiotherapy alone. Hysteroscopy was con-
identify whether the myomas is submucous or intramural, firmed to be highly accurate, with sensitivity of 89% and
and be difficult to locate which sides or walls they were in; if specificity of 91%. The sensitivity and specificity of CDF
the endometrial lining is thickened obviously, the endome- were 69% and 75%, respectively. The lack of the endome-
trial polyps could not be excluded, while hysteroscopic trial flow signal was related to the absence of uterine malig-
examination can solve the above problems clearly. Granberg nant pathology. The CDF indexes of pulsatility and resistance
et al. believed that transvaginal ultrasonography is an effec- were not correlated with the endometrial histopathology.
tive way to diagnose endometrial and intrauterine abnormali-
ties, so it can be taken as the first routine examination for 8.1.15.5 Comparisons of Hysteroscopy
patients with abnormal uterine bleeding. For patients with and Sonohysterosalpingography
abnormal or unidentifiable ultrasonic images, or with normal (SHSG) or Saline Infusion Sonogram
ultrasonographic images but continuous symptoms, hyster- (SIS)
oscopy must be performed together with further biopsy so as Rogerson et al. conducted a prospective and comparative
to exclude or identify pathologic conditions. Paschopoulos study of the accuracy in diagnosis of the intrauterine pathol-
et al. compared the accuracy of diagnosis of intrauterine ogies with hysteroscopy and SHSG, and believed that both
lesions between vaginoscopic hysteroscopy and TVS in examinations were well tolerated. SHSG had a higher failure
rate, but less pain scores than hysteroscopy. De Kroon et al. tubal ostia, and has fewer blind spots of examination com-
conducted a prospective observational study of SHSG in 180 pared with rigid hysteroscope. Due to its small diameter
cases, with failed examination of SHSG in 12 (5.6%), and and flexible front tip, it is easy to pass through the hymen in
inconclusive diagnosis in 22 (10.3%). They concluded that young girls or unmarried adult women and into the vagina
SHSG was able to replace 84% of the hysteroscopy, which to inspect the cervix, and sometimes may enter the uterine
could be applied only when SHSG was failed or could not cavity via the cervical canal for visualizing the cavity
make a diagnosis. Descargues et al. compared the results for (Figs. 8.48 and 8.49). In the Hysteroscopic Center of
examination of abnormal uterine bleeding with SHSG and
hysteroscopy. The SHSG had a positive predictive value of
89% and a negative predictive value of 100%. The difficul-
ties of cervix cannulation occurred in 13% of the cases,
which limited the application of SHSG. Krampl et al. com-
pared the diagnostic accuracy for 88 patients with abnormal
uterine bleeding by means of TVS, SHSG, and hysteroscopy
with biopsy. The diagnostic rate of intrauterine lesions was
100% with hysteroscopy and biopsy, 94.1% with SHSG, and
23.5% with TVS. None of the above methods were able to
accurately diagnose the endometrial hyperplasia in about
75% of all cases. However, endometrial pathologies detected
by TVS and SHSG still needs direct biopsy under
hysteroscope.
8.1.15.6 Comparisons of Hysteroscope

and Magnetic Resonance Imaging
(MRI)
The research outcomes reported by Dueholm et al. indicated
that MRI had the same accuracy as hysteroscopy for exclu-
sion of intrauterine abnormalities, and were slightly superior
to TVS. Both MRI and TVS tend to miss endometrial abnor-
Fig. 8.48 Uterine septum under fiber hysteroscope
malities, which were inferior to hysteroscopy. Dykes et al.
reported that the diagnosis of severe intrauterine adhesions
with MRI were correlated with hysteroscopy.
8.1.16 Minimally Invasive Diagnostic

Hysteroscope
Following the advent of micro-hysteroscope, the Olympus

Corporation of Japan released minimally invasive diagnos-
tic hysteroscope in 2001 with the telescope of 1.9 mm and
the outer sheath of 3 mm. Non-invasive techniques were
driven by the equipment miniaturization, so that the hyster-
oscopy can be safely carried out in outpatient setting. Fiber
hysteroscope has its unique characteristics among many
available hysteroscopes, whose objective scopes have dif-
ferent sizes of 3.1 mm, 3.6 mm, and 4.9 mm in outer diam-
eter. Generally, dilation of cervix and anesthesia are not
needed during examination, except for a few menopausal
women and some patients with extremely narrow cervical
canals caused by adhesions. The front tip of fiber hystero-
scope can be bent for 90°–120° towards both sides, so that
it is convenient to show the uterine cornua and the fallopian Fig. 8.49 Intrauterine adhesions under fiber hysteroscope
Fuxing Hospital, Capital Medical University, the flexible hemoglobin at certain wavelengths to improve the contrast of
fiber hysteroscope has also been used for inspection of the blood vessels in superficial endometrial layer and well dis-
vaginal wall cyst. In an unmarried woman with a ruptured play the mini-structure of the endometrium, therefore it
cyst in the vaginal wall, the telescope was inserted from the could facilitate the identification of endometrial atypical
defect of the cyst to look into the intracapsular structure lesions and achieve the aim of early diagnosis.
and take samples of the cystic wall tissues, which was diag-
nosed pathologically to be Mullerian duct cyst. HYF-1T 8.1.17.1 Principles of NBI
fiber hysteroscope with an insertion tube of 4.9 mm in outer Xenon, which is known as “White light,” is applied as light
diameter and the rigid hysteroscope with operating channel source in traditional endoscopic surgery, with its spectrum
and 4.5 mm in outer diameter can also be used to remove being composed of three-primary colors - red, green, and
the vaginal foreign bodies of young girls. If the uterine cav- blue, and its wavelengths range from 400 nm to 700 nm. In
ity is too wide, it will not be easy to control the direction NBI system, white light is filtered through an optical filter to
when using a fiber hysteroscope, as it has a relatively small produce blue light (the central wavelength of 415 nm) and
visual field. Therefore, it is not suitable to be used in green light (the central wavelength of 540 nm), both of which
patients with large uterine cavity, large intrauterine lesions are prone to be absorbed by hemoglobin. The hemoglobin
or complicated conditions. Burke applied an Olympus flex- obtains the first absorption peak at 415 nm wavelength (blue)
ible hysteroscope with a Cook catheter and a combined and the second peak at 540 nm (green), so the blood vessels
laparoscopy to perform a tubal cannulation in the treatment containing much more hemoglobin will be darken after the
of 120 women with bilateral interstitial tubal obstruction. absorption of blue and green lights, while the surrounding
After treatment, post-operative tubal patency was achieved endometrium appears to be relatively bright, which highlight
in 96 cases, and pregnancy occurred in 48 cases, two of the contrast of vessels. In addition, light has the characteris-
which were ectopic. Reocclusions of the tubes occurred in tic that its penetration ability is directly proportional to
12 women, of which 8 were retreated with catheterization wavelength. The capillary vessels in the surface of endome-
and two achieved normal pregnancy. The only complication trium mainly absorbs blue light and appears blue, while
was a uterine cornual perforation with the tubal catheter. blood vessels in deep layer of endometrium or in submucous
The results indicated that hysteroscopic tubal cannulation layer absorb green light and appear green, both of which
was effective in treatment of interstitial tubal obstruction. make the visualization of blood vessel distributions in endo-
Lin et al. reported their experiences of removing intrauter- metrium clearer.
ine devices (IUDs) in 33 cases of early pregnancy. When
the IUDs were not visible from cervical canal, it could be 8.1.17.2 Clinical Applications of NBI
removed with flexible hysteroscope without cervical dilata- Folkman firstly carried out several pieces of research and
tion and anesthesia. IUDs were found in the uterine cavity found that both the occurrence and the development of
in 30 women, and were removed in 28. There was no IUD tumors relied on the generation of blood vessels, and the
observed in the remaining 3 women. All women were fol- intensity of the vessels suggested the presence of malignant
lowed-up until delivery, with 24 healthy children born. 6 tumors. In 2001, Sano et al. first reported the administration
other women performed curettage 1–2 weeks after the of NBI in gastrointestinal endoscopy to infer the extent and
removal of IUDs. Others were lost to follow-up. Ross used the degree of the lesions from displaying the abnormal ves-
flexible minihysteroscopes to examine the urethra, bladder sels in pathological areas, thus helping gastrointestinal endo-
and colon in 225 patients, with the findings of chronic scope to diagnose digestive system tumor and precancerous
urethritis in 13 cases, significant urinary symptoms in 18 lesions, and increase the accuracy rate of biopsy. Nowadays
patients, of which 3 were found to have interstitial cystitis NBI is mostly applied in diagnosis of digestive system disor-
and mucosal ulcer. 194 patients with stress incontinence ders, and is more and more utilized in diseases of otolaryn-
were examined and it was found that the stability of bladder gology, respiratory system and urinary system. However,
neck decreased while coughing. 17 patients were found to there are relatively few research of its application in gynecol-
have sphincter dysfunction. ogy and obstetrics. In 2007, Farrugia et al. first applied NBI
in gynecologic endoscopic surgery, and in recent years they
mainly studied the use of NBI in laparoscopic removal of
8.1.17 Narrow Band Imaging Hysteroscopy pelvic endometriosis and removal of peritoneum metastasis
of ovarian carcinoma. In 2009, Surico et al. first used NBI in
Narrow band imaging (NBI) is a new optical image enhance- hysteroscopy to diagnose endometrial pathologies, and con-
ment technique, which was developed by National Cancer cluded that NBI could clearly identify the structures of capil-
Center Hospital East, Japan and Olympus Medical Systems lary vessels and diagnose endometrial lesions via the
(Tokyo, Japan). It utilizes the light absorption properties of observation of irregular and thickened vessels. In 2010, Fujii
et al. reported the use of NBI in colposcopy, which could 8. Endometrial cancer: The neoplasm appears to be polyp-
increase the diagnostic rate of cervical cancer in situ and cer- oid, gyriform or cauliflower-like. The blood vessels are
vical adenocarcinoma. increased in numbers and distributed irregularly with the
calibers uneven in thickness and the shapes curly and spi-
8.1.17.3 Characteristics of Intrauterine rally (Fig. 8.57a–c).
Pathology Under NBI Hysteroscopy
1. Normal proliferative endometrium: The endometrium 8.1.17.4 Clinical Applications of NBI
appears to be smooth and flat with an even color and Hysteroscopy
without abnormal vascular networks (Fig. 8.50a, b). Both endometrial hyperplasia and endometrial cancer are
2. Endometrial polyps: The neoplasm is characterized by a common in gynecological disorders, and the early diagnosis
vascular axis and longitudinal dendritic branch vasculars and treatment have significant influence on prognosis of
which derive from the pedicle (Fig. 8.51a, b). endometrial cancer and precancerous lesions. Trimble et al.
3. Postmenopausal atrophic polyps: The neoplasm is char- reported that in women who had been previously diagnosed
acterized by a vascular axis and irregular vascular net- as atypical endometrial hyperplasia by biopsy and histopath-
work (Fig. 8.52a, b). ologic examination, the morbidity of endometrial cancer was
4. Uterine leiomyomas: Large main vessels and branching up to 42.6%. Thus, a precise target biopsy is the key to
vasculars deriving from them can be visualized on the increase the diagnostic rate, and the hysteroscopy has been
surface of the white neoplasm (Fig. 8.53a, b). an optimal technique in diagnosing intrauterine pathology,
5. Chronic endometritis: In these cases, the endometrium is which can be detected under direct vision and facilitate tar-
interspersed with uneven blue petechiae, with the superfi- get biopsy. However, it was reported that the sensitivity of
cial or subepithelial vascular network expanding, or tiny diagnosing endometrial hyperplasia and endometrial carci-
papillary foci with vascular axis existing (Fig. 8.54a, b). noma by traditional hysteroscopy under white light was
6. Low risk endometrial hyperplasia (simple and complex 56.3% and 80%, respectively. The properties of NBI tech-
hyperplasia): The endometrium is thickened and uneven nique provide us a possibility of early detection of endome-
with subepithelial vascular network visible (Fig. 8.55). trial diseases. In 2009, Surico et al. firstly utilized NBI
7. High risk endometrial hyperplasia (atypical hyperplasia): technique in hysteroscopy to perform NBI diagnostic hyster-
The endometrium is thickened with its surface uneven or oscopy in patients with postmenopausal abnormal uterine
polypoid. The number of vessels is increased with irregu- bleeding, and discovered that micro-vascular structures
lar and messy vascular branches visible (Fig. 8.56). could be clearly visualized under NBI, which could help sur-
a b
Fig. 8.50 (a) Normal proliferative endometrium under white light. (b) Normal proliferative endometrium with NBI
a b
Fig. 8.51 (a) An axial blood vessel in an endometrial polyp with NBI. (b) Branch vessels in an endometrial polyp with NBI
a b
Fig. 8.52 (a) Vascular networks in a postmenopausal endometrial polyp with NBI. (b) Blood vessels coming from the pedicle in a postmeno-
pausal endometrial polyp with NBI
a b
Fig. 8.53 (a) Thick and large blood vessels in an uterine myoma with NBI. (b) Regular branch blood vessels in an uterine myoma with NBI
a b
Fig. 8.54 (a) Expanded vascular network and scattered bleeding spots in chronic endometritis with NBI. (b) Tiny polyps in chronic endometritis
with NBI
geons to identify the suspicious foci with very tiny, intensive nosis of endometrial lesions. In 2010, Surico et al. carried
and irregularly arranged micro-vasculars. These indicated out a prospective study on 209 women with abnormal uterine
that NBI could improve the accuracy of the identification of bleeding. Diagnostic hysteroscopy with white light and NBI
endometrial cancer and endometrial hyperplasia, and could was taken in each woman, and endometrial direct biopsy fol-
be considered as an effective auxiliary method for early diag- lowed. The results indicated that the sensitivity and specific-
ity of traditional white light hysteroscopy in diagnosing

endometrial cancer were, respectively, 84.21% and 99.47%,
and those in diagnosing endometrial hyperplasia were
64.86% and 98.77%. However those of NBI hysteroscopy
were 94.74% and 98.36%; 78.38%, and 98.88%, respectively,
therefore NBI could significantly increase the diagnostic
sensitivity. Cicinelli et al. reported that diagnostic hysteros-
copy was taken in 395 women and NBI hysteroscopy was
discovered to have a higher specificity (0.93:0.78) and nega-
tive predictive value (0.92:0.81) than white light hysteros-
copy to make diagnosis of disorders. Thus it can be concluded
that the diagnostic accuracy of normal endometrium with
NBI hysteroscopy was higher than that with white light hys-
teroscopy, both of which could achieve a higher diagnostic
accuracy for diagnosing endometrial polyps and myomas
(95.3–100%). NBI hysteroscopy could obtain higher sensi-
tivity than white light hysteroscopy for the diagnosis of
chronic endometritis (0.88:0.70), low risk endometrial
hyperplasia (0.88:0.70), and high risk endometrial hyperpla-
sia (0.60:0.40). Furthermore, NBI could improve the positive
predictive values of endometritis (0.95:0.69) and high risk
endometrial hyperplasia (0.75:0.40), and decrease the false
Fig. 8.55 Vascular networks in endometrial simple hyperplasia with negative values as well. Tinelli et al. reported a multicenter
NBI study about NBI hysteroscopy being applied in 801 outpa-
tient women. It was found that, with NBI hysteroscopy and
white light hysteroscopy, the sensitivity in diagnosing low
risk hyperplasia was 82% and 56%, respectively; in detect-
ing high risk atypical hyperplasia was 60% and 20%; and in
diagnosis of endometrial cancer was 93% and 81% which
indicated that NBI hysteroscopy could decrease the missed
diagnosis of endometrial severe lesions thus improving the
diagnosis of precancerous lesions and malignant tumors. In
addition, NBI may also be applied in flexible hysteroscope
and can achieve a higher diagnostic rate of endometrial atyp-
ical hyperplasia and endometrial cancer than white light hys-
teroscopy. In 2011, Ercan et al. studied the application of
NBI for evaluating the intrauterine abnormalities of infertil-
ity. Diagnostic hysteroscopy was performed in women who
failed in IVF treatment. Among 8 women with no endometri-
tis identified under white light hysteroscopy, 3 were diag-
nosed as endometritis when NBI hysteroscopy was applied.
Therefore NBI hysteroscopy is also useful in examination of
women with unexplained infertility.
Although the NBI technique has not been applied for a
long time in diagnostic hysteroscopy, the above studies sug-
gest that it could improve the sensitivity of early detection
for endometrial carcinoma and precancerous lesions.
Therefore NBI holds promise to be a commonly used tech-
Fig. 8.56 Uneven in thickness and messy in distribution of blood ves- nique in hysteroscopy.
sels in endometrial complex atypical hyperplasia with NBI
a b
Fig. 8.57 (a) Uneven in thickness and messy in distribution of blood vessels in endometrial adenocarcinoma with NBI. (b) Polypoid endometrial
cancer with NBI. (c) Endometrial adenosarcoma with NBI
8.1.18 Does Diagnostic Hysteroscopy in patients who underwent hysteroscopy and D&C, or D&C
Facilitate the Dissemination of Tumor without hysteroscopy. They conducted a multicentric, retro-
Cells? spective cohort analysis of 113 patients with endometrial
carcinoma staging Ia or Ib in the year of 1996–1997. Positive
Whether diagnostic hysteroscopy facilitates the dissemina- peritoneal cytology was obtained during laparotomy and was
tion of tumor cells has always been the most concerned and defined as detection of malignant or suspicious cells. The
controversial question among scholars. There have been sev- results showed that peritoneal cytology was suspicious or
eral reports on endometrial tumor cells disseminating into positive in 10 of 113 patients (9%), which was associated
the abdominal cavity, which was suspected to be caused by with an intrauterine procedure of hysteroscopy (P = 0.04) but
hysteroscopy with fluids distention and irrigation. Obermair had no relationships with myometrial invasion (P = 0.57),
et al. evaluated the incidence of positive peritoneal cytology histological types (P = 1.00), staging (r = 0.16, P = 0.10), or
the intervals between D&C and laparotomy (r = 0.04, sooner or later as a warning symptom of most intrauterine
P = 0.66). The research outcomes published by Kuzel et al. lesions. Since it is often related to pregnancy, AUB in young
were concordant with those by Kobilkova, that is, no detri- women has tended to become less as an indication for hys-
mental result was found by cytological examination with teroscope, while for menopausal women, AUB is the stron-
hysteroscopy being followed with target biopsy in women gest indication for diagnostic hysteroscopy since it has very
with endometrial cancer, while the tumor cells would appear little relation with fertility. Due to the various research fields
at posterior fornix after the curettage. These limited litera- of each gynecologist, the number of diagnostic hysteroscopy
tures strongly support the point that hysteroscopy with fluid performed on women with AUB is different.
distention and irrigation do facilitate tumor cell dissemina- AUB is a main indication for hysteroscopy. Among 500
tion, but it has not been verified whether it will cause tumor cases reported by Porto in 1974, 48% had uterine bleeding.
cell invasion and metastasis, thus further studies are required. Of 320 cases reported by Sciarra and Valle in 1977, 49.6%
had uterine bleeding. Of 680 cases reported by Hamou,
37.5% had uterine bleeding. Barbot reported that, in one
8.2 Applications of Hysteroscopy study group of 810 patients who were unrelated to pregnancy
in Gynecological Diseases and had examinations by contact hysteroscope, 64.8% of
whom mainly complained of AUB. Among his later report of
Enlan Xia 1500 cases of hysteroscopy, AUB took up 52.1% of the
cases, so roughly one in two hysteroscopies was performed
for AUB.
8.2.1 Abnormal Uterine Bleeding
8.2.1.2 Hysteroscopic Techniques Related
Abnormal uterine bleeding (AUB) is the earliest and the to Uterine Bleeding
most common indication for hysteroscopy. Nagele et al. per- Diagnostic hysteroscopy can be performed very easily if
formed 2500 hysteroscopies in an outpatient setting, 87% of there is no uterine bleeding. However, if there is, high-level
which were indicated because of abnormal uterine bleeding. techniques are required for both emergency and bleeding fol-
The indication for the first successful hysteroscopy per- lowing ineffective medication. The degrees of difficulty are
formed by Pantaleoni in 1869 was menopausal uterine bleed- varied, which depend on: (1) the amount of bleeding; (2) the
ing. Endometrial polyps on the fundus of uterus was properties of the equipment used; (3) the technique applied;
discovered and cured by hysteroscopy as well. Because the and (4) the experiences of the surgeon.
problem with suboptimal visualization caused by intrauter-
ine bleeding during diagnostic hysteroscopy was not resolved 1. CO2 uterine distension: When CO2 is used as the uterine-
for more than one century, the development of hysteroscopic distending medium, intrauterine blood may lead to the
technology has been postponed. As a result, D&C and the formation of bubbles, blurring of the vision and even
HSG had remained the two major methods of examination obstacle to the whole vision field. The solution is to insuf-
for women with hypermenorrhea until recently. However, flate gas through the outer sheath of hysteroscope with an
now a great number of research have confirmed hysteros- inflow channel opened at the front tip so that the airflow
copy to be the most accurate and reliable way of intrauterine may clean the surface of the objective lens and remove
examination. bubbles and blood. If this method cannot provide a clear
By direct observation of the bleeding lesions, not only can vision either, the end of objective lens can be attached to
hysteroscopy improve the gynecologists’ understanding of the mucosa of the uterine fundus, by which a satisfactory
AUB, but also a variety of intrauterine lesions can be man- vision can usually be restored. If it fails again, the telescope
aged by the advanced hysteroscopic surgery, which totally should be taken out and soaked in sterile saline or clean
changes the previous therapeutic procedures. The conven- water. If there is massive hemorrhage, the blood clots may
tional interventions, such as repeated curettage and hysterec- block the gas injection channel and cause the closure of
tomy, have not been applied any longer. For most cases, the cavity, hence the images in front of the objective lens
high-frequency electric or laser surgery, which have a long- seem to be blanketed by a red curtain. The method of con-
term effectiveness on intrauterine benign lesions, have firming the blockage is that no emergence of bubbles is
become conservative treatment modalities for intrauterine observed when the hysteroscope is withdrawn and
benign lesions. immersed in water. The gas-injection valve is connected to
a syringe and the water is injected under a higher pressure,
8.2.1.1 AUB Among Indications for Hysteroscopy which can clear out the blocked channels. Sometimes the
AUB is the most common complaint of the women who vision is clear, but under the air pressure, the blood clots
come to the gynecologic outpatient clinic, and it may appear may extend to the posterior wall of the uterus and cover
the uterine cornua. If the bleeding points are just located in Table 8.4 Hysteroscopic findings in 768 patients who had AUB at dif-
this site, it might not be detected before the removal of the ferent age groups
blood clots. The remedy is to place a catheter into the uter- In women with child- In postmenopausal
bearing age women
ine cavity with its end connected to a syringe, by which
Common Uterine myomas Endometrial
the blood clots are sucked out under direct vision. findings Endometrial hyperplasia hyperplasia
Sometimes when the bubbles are forming, the surgeon Endometrial polyps Endometrial polyps
should wait patiently for a while because the vision might Placenta polyps Endocervical polyps
become clear suddenly and the bubbles might disappear Decidua (ectopic Uterine myomas
pregnancy) Endometrial atrophy
abruptly, the process of which may be accelerated due to Endometrial atrophy Endocervical cancer
the regulation of the air flow pressure (higher or lower). Adenomyosis Adenomyosis
Due to the short period in sustaining a clear view, the sur- Endocervical cancer
geon must be ready to make a rapid diagnosis. If the vision
is seriously limited, and a comprehensive and reliable
diagnosis cannot be made, other uterine-distending tech- findings, followed by endometrial atrophy and endometrial
niques should be considered. carcinoma.
2. Hyskon uterine distension: Being a high-viscosity uterine
distending medium, Hyskon is not easy to be mixed with 8.2.1.4 Roles of Hysteroscopy in the Diagnosis
blood, so it is suitable to be applied for women with of Non-pregnancy AUB
severe bleeding or when uterine distension with CO2 Most intrauterine benign lesions are endometrial polyps,
fails. The intrauterine hematocele should be removed first submucous myomas, and endometrial hyperplasia, which
before it is in use so as to keep a clear view. have different features. The initial symptoms of those lesions
3. Low viscosity distending medium: Low viscosity dis- are often AUB, which cannot be diagnosed by gynecological
tending media include normal saline, 3% sorbitol, 5% examinations like speculum examination and bimanual
mannitol, 1.5% glycine, Ringer lactate solution, etc., examination. In recent years, it has been fully proved that the
which are convenient for application and safer than high standard diagnostic procedures to explore and identify these
viscosity distending media. In diagnostic hysteroscopy, lesions are not reliable. In the interpretations of HSG abnor-
the operating is short and so the risk of fluid overload is mal images, 30–50% of them are uncertain or even incorrect.
minimal. D&C cannot remove the uterine myomas, and often miss
4. Contact hysteroscopy: Another alternative technique is endometrial polyps as well. However, accurate diagnosis is
the contact hysteroscopy. After the contact of the objec- required clinically to be able to identify these three kinds of
tive lens with the mucosa, the intrauterine hemorrhage lesions, and also to suggest correct method of treatment.
volume is not a problem any longer. The only restriction With extensive application of hysteroscopy, diagnostic hys-
is that the surgeon must be proficient in this technique teroscopy has been highly valued and applied in the diagno-
and be able to interpret the images correctly. While faced sis of chronic endometritis recently.
with difficult-to-control bleeding, contact hysteroscope
should be replaced by hysteroscope with continuous per- Endometrial Polyps
fusion. Such hysteroscope is equipped with two channels: Diagnosis
inflow channel and outflow channel. After the entry of Due to the lack of typical and constant symptoms, endome-
fluid into the uterine cavity, the intrauterine blood and trial polyps are usually difficult to be accurately diagnosed
debris can be washed out while the uterus is distended so clinically. In diagnosing endometrial polyps, space-
that the surgeon can observe the whole uterine cavity occupying lesions like filling defects or an irregular uterine
clearly. wall might be revealed under HSG, but it is easy to be con-
fused with submucous myoma and bubbles, and excessive
8.2.1.3 Hysteroscopy for AUB injection of contrast media can mask polyps. Sometimes
Barbot reported the hysteroscopic findings in 768 patients typical polyp can be scraped off by D&C, thus a confirmed
who had AUB at different age groups (Table 8.4). In women diagnosis may be made. However, it is more likely to miss
of childbearing age, uterine myomas, endometrial hyperpla- scraping the polyp which is too small or too large. Since it
sia, and endometrial polyps were the most common findings lacks a specific structure, a polyp is hard to be diagnosed
under diagnostic hysteroscopy, which almost accounted for pathologically once it is curetted into debris, which may only
more than a half (54% of the cases in a group reported by be reported to be the proliferative endometrium or endome-
Barbot), followed by the bleeding associated with pregnancy. trial hyperplasia. Therefore, there is high rate of false nega-
In menopausal women, endometrial hyperplasia, endome- tive results. It can be concluded that both HSG and D&C
trial polyps and uterine myomas were the most common have limitations in diagnosing endometrial polyps, so if the
patients have such clinical symptoms as menorrhagia, pro- complete scraping of the endometrium for examination is
longed menstruation, continuous dripping, and infertility, suggested for women over the age of 40 years, and then the
especially if HSG is abnormal or cervical or endocervical hysteroscope is inserted again to make sure that the uterine
polyps found during gynecologic examinations, hystero- cavity has been emptied so as not to miss any early lesions of
scopic examination should be considered so as to determine endometrial carcinoma. In 2007, Timmermans et al. reported
whether there exists any endometrial polyp or not. According 178 patients with postmenopausal bleeding and endometrial
to Angioni’s report, in diagnosis of endometrial polyps with thickness >4 mm with ultrasonography examination.
hysteroscopy, the sensitivity was 100%, the specificity was Endometrial polyps were found in 90 patients (50%) with
97%, and the accuracy was 91%, which were almost hysteroscopy. Burke et al. reported that endometrial
absolutely consistent with the postoperative pathologic diag- pathology was diagnosed in five women when they had been
nosis. Spiewankiewicz et al. discovered that, in 65 patients investigated for infertility, with atypical polypoid adenomy-
with polyps found in the cervical canals with gynecological oma in three cases, complex endometrial hyperplasia in one
examinations, six were diagnosed as endometrial polyps and stage 1 endometrial adenocarcinoma in one. Only the
under hysteroscopy. In another 13 patients, cervical polyps last patient had menstrual abnormality. They believed that
were identified by gynecological examination, which were the possibility of detecting endometrial pathologies increased
confirmed to be endometrial polyps under hysteroscopy. during fertility investigations, because women in this cate-
Under hysteroscope, endometrial polyps can protrude gory are likely to be older and obese. Antunes et al. reported
from any site of the uterine wall and at any angle into the that among 475 cases of perimenopausal and postmeno-
uterine cavity, which may also be found in the cervical canal, pausal women with endometrial polyps identified, atypical
or just located in the uterine cornua, causing blockage of the hyperplasia was found in 1.05% of cases, and endometrial
fallopian tubal ostia (Fig. 8.58a). The size of polyps gener- polypoid cancer in 2.74%.
ally ranges from 0.2 cm to 3 cm, which can be single
(Fig. 8.58b–d) or multiple (Fig. 8.58e), and one polyp may Submucosal Myoma
have two pedicles (Fig. 8.58f). A polyp is soft, shiny, and Diagnosis
even floating in appearance, with the color being bright red,
which is similar to the surrounding endometrium, but there 1. Submucosal myoma: It is usually easy to diagnose. Its
are also exceptions occasionally. A polyp does neither float typical hysteroscopic appearance is one of a circular
in flowing distention fluid as an endometrial debris nor is it mass, which protrudes into the uterine cavity (Fig. 8.59a,
as solid and firm as the submucous myoma. The polyps are b). The endometrium covering the myoma usually
mostly oval but also triangular, conical, or irregular in shape appears to be atrophic with its color brighter than its sur-
(Fig. 8.58g, h). They have smooth surface, under which fine rounding endometrium. On its surface, a dilated vascular
microvascular networks can sometimes be seen. Most polyps network is visible (Fig. 8.59c). When the myoma is
have pedicles, which are long and thin, or short and wide. touched with the end of the objective lens, it feels hard in
Occasionally, the top surface of larger polyps is accompa- texture, and interferes with the introduction of the tele-
nied by necrosis, which appears to be purple-brown. The scope, which can only bypass it from its side and goes
morphology of polyps does not change with an increase or into the upper cavity. If a submucosal myoma has a pedi-
decrease in uterine-distending pressure. cle, it may be difficult to be differentiated from endome-
trial polyps (Fig. 8.59d). When extending to the cervix,
Values of Hysteroscopy the myoma turns flat, and becomes redder in color at its
Diagnostic hysteroscopy can make a correct diagnosis, and end (Fig. 8.59e, f).
an experienced hysteroscopist can obtain visually guided 2. Intramural myoma: The endometrium covering the sur-
samples for histopathological examination, after which a face of the intramural myoma is the same as the surround-
final diagnosis can be made by pathologists. The polyps may ing endometrium in appearance, except that it protrudes
be scraped into pieces by blind curettage, which may be slightly into the uterine cavity, so it is easy to be missed
mixed with endometrial debris, causing difficulty in histo- in diagnosis by hysteroscopy (Fig. 8.59g, h). The only
pathological examination. During a diagnostic hysteroscopy, indication for intramural myoma may be that the sym-
a relatively complete polyp may be taken out, and the histo- metry of uterine cavity disappears (Fig. 8.59i) when the
pathological examination can reveal any transformation hysteroscope is placed at the internal orifice of cervix.
from a benign polyp into endometrial adenocarcinoma.
Similarly, a thorough direct inspection of the uterine cavity Values of Hysteroscopy
may reveal other lesions concomitant with endometrial pol- The diagnostic hysteroscopy is of great value in the diagno-
yps, such as endometrial hyperplasia or submucous myoma. sis of submucous myoma, especially the small ones which
Finally, after selective resection of endometrial polyps, a are located in the uterine cavity causing severe bleeding, but
cannot be detected by internal examination. When HSG can- ate, thus leading to continuous abnormal bleeding. Even
not be done due to continuous bleeding, a prompt diagnosis when myoma of uterus is detected during bimanual examina-
can be made by hysteroscopy, and unnecessary D&C is tion occasionally, myoma cannot be taken lightly as the
avoided. Sometimes the existence of submucosal myoma can cause of bleeding. Hysteroscopy can often avoid misdiagno-
be suspected by “feeling” a firm bulge accidentally during sis due to the presence of intrauterine lesions, such as endo-
D&C, but in most cases it would be missed. Due to the fric- metrial hyperplasia, polyps, or cancer. Angioni et al. reported
tion of myomas in the uterine cavity, the mucosa may ulcer- that hysteroscopy demonstrated a sensitivity of 100%, speci-
a b
c d
Fig. 8.58 (a) Small endometrial polyp in the tubal ostia of left uterine cornua. (b–d) Single endometrial polyp. (e) Multiple endometrial polyps.
(f) Endometrial polyp (double pedicles). (g) Strawberry-shaped endometrial polyp. (h) Endometrial polyp with double pedicles
e f
g h
ficity of 98%, and a diagnosis accuracy of 99% for submu- Hysteroscopic resection of sessile myoma is very difficult, but
cous myomas. The kappa value was 0.82 for hysteroscopy, high-frequency electricity or laser under ultrasonography
which corresponded highly with final pathologic diagnosis. monitoring can be used to resect safely the sessile submucosal
The hysteroscopy is also extremely useful in the choice of myomas embedded in the uterine wall. Before removal of
a proper treatment, which can help patients be treated conser- intramural or subserosal myomas with laparoscopy or conven-
vatively so as to avoid laparotomy or hysterectomy. An accu- tional laparotomy, preoperative hysteroscopy can be per-
rate and noninvasive resection of pedunculated submucous formed to rule out the myoma coexisting in the uterine cavity
myoma can be performed easily by operative hysteroscopy. and avoid a perforation to the uterine cavity during operation.
a b
c d
Fig. 8.59 (a) Submucosal myoma. (b) Submucosal myoma with a Intramural myoma which protrudes into the cavity. (h) Intramural
pedicle on the anterior wall. (c) Submucosal myoma with dilated vascu- myoma which protrudes into the cavity. (i) Intramural myoma, which
lar network visible on its surface. (d) Submucosal myoma with pedi- protrudes into the cavity, leading to compression and deformation of
cles. (e) Submucosal myoma which protrudes out of the cervical os. (f) uterine cavity
Submucosal myoma which protrudes out of the cervical os. (g)
e f
g h

teroscope cannot be compared with the microscope, but it

i
can identify the endometrium in different physiological
phases. The methods for identification lie on four conditions:
endometrial thickness, color, vessels, and texture. Another
difficulty is associated with hysteroscopic techniques. The
examination of a normal endometrium on the same day by a
contact hysteroscope with gas uterine-distension or liquid
uterine-distension may get completely different results.
Without any artificial distention of the uterine cavity, contact
hysteroscopy may certainly obtain the results closest to the
actual condition of the endometrium. In the late proliferative
stage, the endometrium is thickened and wavelike, with
many wrinkles on its surface. Such a change is not a polyp-
oid hyperplasia and such a feature can be maintained under
contact hysteroscopy, but due to the compression of the con-
tact hysteroscope, the endometrium turns into pink-and-
white, the blood vessels become less and thinner, and the
tissues may be divided or fragmented.
Endometrium at secretory phase (Fig. 8.60d) appears to
be thickened and wavy, but light-colored, greyish, and trans-
Fig. 8.59 (continued) parent; the vessels are significantly increased in number,
with their calibers widened to be sinusoid; and the tissue is
dense and cannot be easily crushed. All of these changes are
Benign Endometrial Hyperplasia caused by the effect of progesterone. The panoramic hyster-
Diagnosis oscopy which uses CO2 as uterine-distending medium may
Benign endometrial hyperplasia is defined as normal endo- find endometrium flat but its thickness invisible. The pres-
metrium, glands and interstitial cells increased in number sure of the gas causes the uterine cavity to expand and plicae
and density. However, these increases are well coordinated, to disappear. At this time, if panoramic hysteroscopy uses
which still maintain normal ratios. This is the differentiation liquid as uterine-distending medium instead, the endometrial
point between benign (simple endometrial hyperplasia, plicae might reappear and seems to be larger. In spite of
Fig. 8.60a) and atypical endometrial hyperplasia or uterine expansion of the uterine cavity, the endometrium still remains
adenomatous hyperplasia (complex endometrial hyperplasia, like the seaweed, and the outwardly growing shoots are quiv-
Fig. 8.60b), in the latter endometrial glands replace the nor- ering in liquid. An experienced hysteroscopic surgeon must
mal supportive interstitial tissues. According to the above understand these changes so as not to make a false-positive
definition, benign endometrial hyperplasia can be classified or false-negative diagnosis of endometrial hyperplasia.
into several types: (1) simple hyperplasia, which manifests When contact hysteroscopy is performed, simple endome-
as normal endometrium with increase in thickness; (2) pol- trial hyperplasia is similar to preovulatory endometrium in
ypoid hyperplasia, the mucosal surface of which is wave- color, vessels, and texture, and the abnormally thickened
shaped (Fig. 8.60c) and resembles polyps; (3) benign cystic endometrium may form many rugae, accumulating into com-
hyperplasia, in which the glands are enlarged and expanded, pound layers. Simple endometrial hyperplasia is very diffi-
and a “Swiss cheese” form is shown histologically. cult to be diagnosed by panoramic CO2 hysteroscope,
Endometrial hyperplasia can be diffuse or localized. The lat- because the endometrium seems to be flat even though it
ter is isolated and excessive proliferation of endometrial becomes thickened. Porto suggested drawing a furrow in the
cells can be found in normal endometrium. There is some endometrium with the end of objective lens so as to estimate
difficulty in diagnosing endometrial hyperplasia with hyster- the thickness of the endometrium. The features of polypoid
oscopy. Normal endometrium changes constantly through- hyperplasia are obvious, so its diagnosis is relatively easier.
out the menstrual cycle, the thickness of the endometrium Since there is no uterine distention, the polypoid hyperplasia
reaches its peak in late proliferative phase, during which the looks like many leaflets piling up together under the contact
endometrium is not affected by secretion of progesterone, hysteroscopy, the image of which does not disappear when
and the appearance of endometrium is similar to hyperplasia. the uterus is distended, so a panoramic hysteroscope is more
Therefore, the physicians must be familiar with endometrial suitable. The severity of intrauterine lesions under hysteros-
images at different phases of the menstrual cycle so as to copy is associated with the expansion of the cavity. The more
make appropriate hysteroscopic diagnosis. Although the hys- expanding the uterine cavity is, the less obvious are the
a b
c d
Fig. 8.60 (a) Simple endometrial hyperplasia. (b) Complex endometrial hyperplasia. (c) Mucosal surface of polypoid hyperplasia. (d)
Endometrium at secretory phase
lesions. The endometrial cystic hyperplasia can be seen debris can be taken for pathological examination. HSG often
clearly under contact hysteroscope. misses the focal endometrial hyperplasia. At the beginning
of injecting a contrast agent, nonspecific hidden filling defect
Values of Hysteroscopy may sometimes be seen, which disappears after the continu-
Compared with HSG and D&C, hysteroscopy is the only ous injection of the contrast agent. D&C often cannot detect
way to observe the endometrium in vivo inside the human the disorders either. However, with hysteroscopy, it can look
body. The inferences drawn from an irregular contour and directly into the uterine cavity, with the endometrium being
filling defects with HSG are always incomplete. D&C ran- flat or polypoid, diffuse or focal. The extent of lesions can be
dom sampling only offers limited information and blind defined and the diagnosis of focal endometrial hyperplasia
curettage may destroy the endometrial structure, hence only can be made. When focal endometrial hyperplasia is found in
a routine hysteroscopy due to AUB, its relationship with tion of a contact hysteroscopy and the magnification of
AUB should be carefully considered and other causes for images may increase the accuracy of diagnosis and provide
bleeding should also be searched for at the same time. more detailed information.
Endometrial hyperplasia is often accompanied by a high Due to the technical and anatomical reasons, early endo-
estrogen state, so lesions induced by the coexisting estrogen metrial cancer does not manifest as lumpy structure available
stimulation must be considered. The focal atypical endome- for screening, and diagnostic hysteroscopy is usually per-
trial hyperplasia or early endometrial cancer should not be formed due to AUB. Since hysteroscopic images have dis-
missed and a biopsy must be taken from the sites with atypi- tinct characteristics, diagnosis should not be a problem.
cal vessels. One of the advantages of hysteroscopy is that the However, influenced by inspection techniques and equip-
condition of the endometrium can be fully revealed before ment, contact hysteroscopy eliminates the reflection of light,
biopsy sampling or treatment. Focal endometrial hyperplasia making the color of the endometrium more natural and the
is similar to polyps occasionally, and contact hysteroscopy graphics of the blood vessels displayed, enabling the thick-
can be performed earlier in case of doubt. The true polyps ness of lesions to be assessed. Panoramic hysteroscopy is
have pedicles, which are mostly composed of stroma with suitable to be used to determine the location of the tumor, to
typical axial feeding vessels. The pedicles are firmly attached draw an accurate outline of its shape, and to establish its
to the uterine wall and resist the pressure from the hystero- extension. CO2 used in uterine-distention can have a good
scope. However, these structures of focal endometrial hyper- illumination, but make the undulant endometrium be flat-
plasia are not firm and are easy to be penetrated or poked tened, so its surface appears smoother. When fluid is used in
away by hysteroscope. Another advantage of hysteroscopy is uterine-distension endometrial tissue may be extended out-
follow-up of endometrial hyperplasia therapeutic effect. ward, but the field of vision is made narrower and the color
According to the statistics, in a conventional blind curettage, turns white.
25% of the endometrium would not be sampled at all. For Sugimoto described four types of endometrial carcinoma
severe diffuse endometrial hyperplasia, a repeat curettage with fluid used in uterine-distension. (1) Polypoid type: It is
should be performed under the hysteroscopic guidance in polypoid-like in appearance, but irregular in shape with
order to take enough endometrium for histopathology exami- enlarged and twisted blood vessels; (2) Nodular type: It has
nation. If hormone therapy is administered in the patients, a wide base, coarse surface and atypical blood vessels; (3)
diagnostic hysteroscopy can accurately assess the reaction of Papillary type: It has a polypoid or nodular appearance, but
endometrium to progestogen after medication. its surface is covered with tiny papillar projections fluttering
in the distending fluid; (4) Ulcerated type: All the above
Atypical Endometrial Hyperplasia and Endometrial types may finally develop ulcers.
Carcinoma Barbot classified endometrial carcinoma into three types
Diagnosis through an observation of 87 cases with CO2 insufflation. (1)
Atypical endometrial hyperplasia is a precancerous lesion, Exogenous type: It is the most common, and the carcinoma
which may develop into endometrial carcinoma if not treated. tissue is white and growing outward, which is equivalent to
It is even difficult for experienced pathologists to distinguish Sugimoto’s type of nodular and papillary types. These pro-
the differences between atypical endometrial hyperplasia, jections are difficult to manifest themselves when CO2 insuf-
carcinoma in situ, and early invasive carcinoma, so adjunct flation is used, thus hardly be detected; (2) Polypoid type: It
diagnosis with hysteroscopy is brought forward, which could has a feature of the endometrial polyp with a narrow base,
not only diagnose endometrial carcinoma with obvious but a more distinct shape of cylinder, with its surface coarse
malignant appearance but also early carcinoma in situ. and irregular, and vessels enlarged; (3) Medullary type: The
Hysteroscopy has the same diagnostic procedures as colpos- lesions are extensive with the neoplasms whitish and irregu-
copy, that is, to identify the most suspicious site for biopsy. lar, and separated by deep grooves, which are similar to brain
However, it is a pity that there is not a single reagent [such as tissues.
acetic acid and compound iodine solution (Lugol’s solution)] Any type of endometrial carcinoma mentioned above can
that can show atypical endometrial hyperplasia and early develop ulcer, necrosis or hemorrhage, making the surface
endometrial carcinoma. So only when the hysteroscopic greyish or yellowish, which may conceal the original lesions
physicians have the knowledge about hysteroscopic images and be mistaken for normal images. The contact hysteros-
of normal endometrium and of various benign endometrial copy may reveal an image of the lesion itself.
hyperplasia, can the more serious abnormalities be diag-
nosed. Close attention should be paid to the endometrial tis- Values of Hysteroscopy
sues which have different colors, fluctuation, and toughness Far in 1907, David reported on observation of endometrial
from the surrounding normal endometrium. For a highly sus- cancer with contact hysteroscope. In 1928, Gauss described
pected neoplasm at the site with atypical vessels, the applica- in detail the findings about neoplasms visible during pan-
oramic hysteroscopy with fluid as uterine distention medium spread of cancer. The same danger also exists during curet-
and drew many pictures. However, HSG and fractional D&C tage. Under laparoscopy, the distending fluid used for pan-
were still the only methods in diagnosing endometrial cancer oramic hysteroscopy can be seen spilling into the abdominal
and determining the extent of its invasion. In 1971, Swedish cavity. When the intrauterine pressure using CO2 insufflation
Joelsson recommended hysteroscopy as a routine method in is too high, PaCO2 proves that CO2 enters the vessels. The
the assessment of endometrial cancer. contact hysteroscopy may have extremely small risk of dan-
AUB is the main symptom for 80% patients with endome- ger in cell dispersion. The essential problem is whether the
trial cancer, so it is more commonly seen in pre-menopausal disseminated cancer cells may lead to plantation and metas-
and post-menopausal women who have undertaken diagnos- tasis of cancer cells or not. Johnson reported that, in a com-
tic hysteroscopy due to AUB, and the detection rate rises parison study of the metastasis rate in patients with
along with an increase in patients’ age. Sugimoto reported endometrial carcinoma who were in group of examination
that among 1824 women who were examined with hysteros- with curettage and HSG, and in group with simple curettage,
copy due to AUB, 53 women had endometrial carcinoma. no significant difference was found. In short, regardless of
Barbot reported that in 1400 cases who had AUB, 56 were what method for diagnosis, there does exist the possibility of
found to have endometrial carcinoma by hysteroscopy. metastasis, but it may not necessarily occur.
Currently, hysteroscopy can provide the most reliable
information about the diagnosis of endometrial cancer and Chronic Endometritis
the extent of intrauterine invasion. Endometrial cytology Diagnosis
smear may provide false negative results, especially for well- In 2005, Cicinelli reported that 35% of patients with chronic
differentiated or small tumors. The result of HSG may be endometritis suffered from AUB. The sensitivity, specificity,
suggestive of endometrial carcinoma, but often misleading. and positive and negative predictive values for diagnosis of
Blind D&C is often inaccurate, and small cancer foci may be chronic endometritis with hysteroscopy for women with
missed in the deep cornua or the rear of the submucosal endometrial hyperemia and edema were 91.8%, 92.9%,
myomas during curettage. In most cases, the tumor may be 63.9%, and 98.8%, respectively; with the diagnostic accu-
clearly observed under hysteroscopy and its outcomes may racy of 92.7%. If concomitant with micropolyps, the sensi-
be predicted. Hysteroscopic examination may reveal a more tivity, specificity, and positive and negative predictive values
obvious outward-extending extent of the tumor than HSG, were 55.4%, 99.9%, 98.4%, 94.5%, respectively, and a diag-
but the depth of myometrial infiltration cannot be detected. nostic accuracy was 93.4%.
Visual inspection cannot replace the pathological diagnosis,
so samples must be taken for histopathological Values of Hysteroscopy
examination. Chronic endometritis is a subtle condition that is difficult to
Diagnostic hysteroscopy can also provide staging for be detected, but may lead to abnormal uterine bleeding and
tumors, as tumor may spread to the uterus (stage I) or invade infertility. Few data exist about the appearance of chronic
the cervix (stage II), for which the treatment and the progno- endometritis at diagnostic hysteroscopy which uses fluid as
sis are completely different. Liukko et al. investigated the distending medium (hereafter referred to as fluid hysteros-
specimens of the removal of uterus which were diagnosed to copy) and about the value of fluid hysteroscopy in the detec-
be endometrial carcinoma stage I by fractional curettage tion of this condition. In Cicinelli’s experience, under fluid
prior to operation and 16% of which were found to be cervi- hysteroscopy, the characterizations of chronic endometritis
cal infiltration postoperatively. Stelmachow reported that was associated with stromal edema and either focal or dif-
among 22 cases with stage I endometrial carcinoma diag- fuse hyperemia and micropolyps (<1 mm in size). Among
nosed by HSG and D&C, 9 were proved to be with stage II 910 cases in his research, hyperemia and edema were
by diagnostic hysteroscopy; and among 9 cases who had detected in 158 patients (17.4%), including micropolyps in
been diagnosed to be with stage II, 2 were actually with stage 61 patients (6.7%). Among 158 patients, 101 (63.9%) were
I. These data indicated the advantages of hysteroscopy in confirmed the diagnosis of chronic endometritis was con-
detecting the infiltration of the cervix. During hysteroscopy, firmed by histopathological examination in 101 cases
the cervical canal is examined with tissues scraped prior to (63.9%).
cervical dilation, thus misdiagnosis is avoided.
Gynecologists are concerned about whether hysteroscopy 8.2.1.5 Role of Hysteroscopy in Diagnosis
can cause focal spread or metastasis of the tumor, and the of Postmenopausal Bleeding
same problem also goes to HSG and D&C. Experimental With the prolonged life span in women and increasingly
studies have shown that the uterine-distending medium widespread applications of hormonal replacement therapy
injected into the uterine cavity during HSG may also flow (HRT) and tamoxifen (TMX), there are more and more cases
into the abdominal cavity and blood vessels, causing the with postmenopausal bleeding (PMB). It was reported that at
least 60% of postmenopausal women suffered from bleed- PMB, except for very few menopausal women or women
ing. Its etiology is complex, with atrophic endometrium as with extreme stenosis of cervical canal due to adhesions.
the most common reason, and hormonal effects as the sec- Due to cervical atrophy in postmenopausal women, a hyster-
ond, being followed by other reasons such as endometrial oscopy should be small enough and also permit a direct
polyps, submucous myoma, IUD, endometrial carcinoma, biopsy through its operating channel. For these women, the
and so on. Its hysteroscopic findings can be classified as atro- operators may use fiber hysteroscope to investigate the cervi-
phic endometrium, irregular endometrial hyperplasia, endo- cal canal from the squamocolumnar junction above the
metrial polyps, submucous myoma, and suspected external orifice of the cervix, to observe the whole uterine
endometrial cancer. Due to their potential risk of endometrial cavity without any blind spots, and to take targeted biopsy at
cancer, it is very important to investigate the cause of the any suspected sites. Once the endometrial polyps are discov-
bleeding. ered, they should be immediately removed. If there is endo-
Currently, the diagnostic methods are D&C, transabdomi- metrial hyperplasia, biopsy can identify whether there is
nal ultrasonography, transvaginal sonography (TVS), sono- cellular atypia or not. If endometrial adenocarcinoma is
hysterography (SHSG), diagnostic hysteroscopy, computed found, staging should be done immediately. The failure rate
tomography (CT), and so on. Gimpelson and Rappold car- of a fiber hysteroscopy was reported less than 3%, and that of
ried out a study on 276 women who underwent both hyster- a rigid hysteroscopy was twice higher. A comparison was
oscopy and D&C. More information was revealed in 44 made of a series of data on the results following diagnostic
cases with hysteroscopy, and in nine cases with hysteroscopy in 286 patients from France, 444 patients from
D&C. Hysteroscopy was especially superior to D&C in Japan, and 251 patients from Belgium who were in peri-
making an accurate diagnosis of endometrial polyps and menopausal period (age ≥49 years old with amenorrhea
submucous myoma. Hysteroscopy revealed the pathological <1 year) or post-menopausal period (amenorrhea for 1 year),
conditions in some of these patients while repeat curettage and with uterine bleeding. It was found that 49–50% of the
showed no abnormalities. Usually, 10–35% of the i ntrauterine patients had normal atrophic endometrium, 25–26.9% had
lesions may not be detected by D&C, especially endometrial polyps, 13.9% had pedunculated, submucosal or intramural
polyps and submucous myoma. Therefore, in the endoscopic myoma, 4.2–8.3% had endometrial hyperplasia, and 2.1–
era, blind D&C should no longer be a main method. Among 3.8% had adenocarcinoma. There were no differences in the
the various examination methods, TVS and hysteroscopy, detection rates between these countries, and the lowest fail-
especially biopsy under direct vision of hysteroscope is the ure rate was found with fiber hysteroscopy in France. It was
most accurate method. From the data reported by Valenzano concluded in this paper that fiber hysteroscopy had a higher
et al., it was suggested that the sensitivity of detecting intra- diagnostic accuracy than that of TVS, as TVS may miss
uterine disorders in women with PMB was 90% with TVS some focal hyperplasia or adenocarcinoma. Even with endo-
and 93% with hysteroscopy. However, the specificity of TVS metrial findings by TVS and SHSG, direct biopsy under hys-
was only 30%. Alcazar and Laparte also pointed out that in teroscope would be required. Therefore, fiber hysteroscopy
the diagnosis of PMB, both TVS and hysteroscopy had high is superior to TVS in examining lesions from uterine bleed-
sensitivity, but hysteroscopy had a higher specificity than ing in perimenopausal and postmenopausal women for the
TVS. Therefore, hysteroscopy has the highest diagnostic following four reasons. First, taking the thickness of double
value to etiology of PMB. Outpatient diagnostic hysteros- layers of endometrium without hormone therapy <4 mm as
copy should become the preferred method of examination cut-off point, the rate of missed diagnosis of abnormal endo-
for PMB due to its high degree of accuracy and acceptability metrium is 5.5% by TVS but the accuracy rate of targeted
of the patients. Now patients can receive hysteroscopy in biopsy by fiber hysteroscopy is higher than 94%. Second,
outpatients, and hysteroscopic assessment of PMB has been both early endometrial hyperplasia and endometrial adeno-
very popular in some countries. Hysteroscopy can have a carcinoma are focal. TVS may easily miss the diagnosis
direct view of the intrauterine lesions in women with PMB while fiber hysteroscopy can observe and take a biopsy under
such as endometrial polyps, submucous myoma, focal endo- direct vision. Third, sometimes the determination of the
metrial pathology including endometrial adenocarcinoma extension of the tumor or lesions requires more than two
and its precursors. Meanwhile, biopsy of suspected sites can biopsies, and fiber hysteroscopy can investigate under direct
be taken to confirm these pathological conditions so that the vision and take multiple biopsies. Fourth, abnormal findings
sampling error may be avoided. However, hysteroscopy is of TVS need to be confirmed by pathology and direct biopsy
still an invasive procedure which takes a little longer. can be performed by fiber hysteroscopy.
In recent years, the flexible fiber hysteroscope produced Correctly judgment of endometrial lesions under hystero-
by Olympus Corporation in Japan is entirely applicable to scope is the key to the improvement on the accuracy of hys-
PMB, which generally does not require cervical dilation and teroscopic diagnosis. Generally, the uterine cavity with
anesthesia, thus reducing the discomfort of patients with atrophic endometrium is smaller, with contour and bilateral
tubal ostia clearly visualized, and the endometrium appears endometrium at the proliferative phase is red with smooth
to be thin and smooth, orange or white, and sometimes the surface, and the regularly-distributed white-spot glandular
punctiform and patchy blood spots, or capillary network are openings are visible with fine vascularity. The intrauterine
visible underneath the mucosa (Fig. 8.61a, b). There may be endometrium involving hyperplasia are thickened totally or
no tissues scraped with curettage after examination. The partially (Fig. 8.61c, d), which seems like pile blanket with
a b
c d
Fig. 8.61 Atrophic endometrium under the flexible hysteroscope. (a) Endometritis under the flexible hysteroscope. The endometrium appears
A relatively smaller uterine cavity and clear tubal ostia are visible, and to be dark red with congestion patches visible. (f) Endometrial polyps
the endometrium is filmy and smooth. (b) A relatively smaller uterine under the flexible hysteroscope. The polyps have papillary protrusions
cavity with a clear contour is visible, and the endometrium is filmy, and smooth surface. (g) Submucosal myoma under the flexible hystero-
smooth and yellowish white. Endometrial hyperplasia under the flexi- scope. The right posterior wall is hemispherically bulged, with its sur-
ble hysteroscope. (c) The endometrium is diffusely thickened and face pale and blood vessels visible. Endometrial carcinoma under the
seems like a pile blanket, orange colored, and shiny. (d) The posterior flexible hysteroscope. (h) The thickened and irregularly-run blood ves-
wall of uterus is seen to be focally thickened, light yellow, and shiny. (e) sels are visible. (i) Atypical vessels and focal hemorrhage are visible
e f
g h

i also miss the diagnosis of some lesions like atypical endo-

metrial hyperplasia and endometrium influenced by hor-
mones, possibly because they have not caused visually
recognizable changes. Therefore, only when hysteroscopy is
performed in combination with pathological examination,
can the diagnosis be made with a high degree of accuracy.
TVS is a non-traumatic examination method, which is
often used in preliminary screening for the causes of post-
menopausal uterine bleeding. Karlsson et al. carried out a
study on the use of TVS and hysteroscopy in 51 women with
PMB. TVS revealed no abnormalities in 12 cases with an
endometrial thickness ≤4 mm, among which hysteroscopy
revealed small endometrial polyps in 1 case. TVS suggested
endometrial abnormalities in 39 cases with an endometrial
thickness >4 mm, while a confirmed diagnosis was made by
hysteroscopy in 35 cases, and the rest four cases were false
positive. There were nine cases with an endometrial thick-
ness ≥8 mm, but hysteroscopy revealed endometrial polyps
in eight cases and endometrial polyp or uterine submucous
myoma in one case. The pathological findings are set as the
Fig. 8.61 (continued) final diagnosis. The sensitivity, specificity, positive predic-
tive value, and negative predictive value of TVS were 100%,
75%, 90%, 100%, respectively, while the corresponding
villi-like protrusions, orange or yellow, shiny, and relatively results of hysteroscopy were 97%, 88%, 94%, 93%, respec-
more transparent. Sometimes vesicle-like structures are vis- tively. So it was believed that TVS screening may be done
ible, and adhesion may occur in severe cases. Endometritis prior to hysteroscopy. O’ Connell et al. reported that the con-
may manifest dark red color with congestion spots and cordance rate of TVS combined with biopsy under hystero-
patches. In severe cases, bleeding or pyometra may occur scope and the surgery was >90%. The sensitivity and
(Fig. 8.61e). Endometrial polyps have soft pedicles with specificity of the combined examination were 94% and 96%,
either fingerlike, ligulate, papillary or mulberry-like protru- respectively. No patients with endometrial hyperplasia or
sions. They are different in shape, with smooth surfaces and cancer were misdiagnosed. So it was believed to be a reliable
bright red colored, similar to the surrounding endometrium, examination method for evaluating PMB. Granberg et al.
and is soft in texture. The small polyps can exhibit wave-like declared that TVS could be used as the first step of routine
motion with uterine distention medium and sometimes slen- examination in the assessment of PMB, and if there was
der vessels are visible (Fig. 8.61f). Uterine submucous abnormal ultrasonography sonography (endometrial thick-
myoma (Fig. 8.61g) is a spherical or hemispherical bulge ness >4 mm), or if it could not be determined, or if there was
with a relatively wider base or pedicle, and doesn’t move normal ultrasonic imaging but continuous symptom in the
with the distending fluid. Its surface appears to be light pink patient, hysteroscopy and hysteroscopic biopsy must be per-
or pale, and purple colored if there is ulcer or hemorrhage, formed simultaneously in order to rule out or detect patho-
and sometimes thickened dendritic blood vessels are visible. logical conditions. Application of hysteroscopy in the
A large myoma may cause the stenosis and deformation of diagnosis of the causes of PMB can be summarized as shown
the cavity, which forms a crescent fissure. The endometrium in Fig. 8.62.
may appear to be obviously hyperplastic in patients with Gumus et al. conducted a prospective study of the values
diagnosed or suspected endometrial carcinoma, which in diagnosing the endometrial abnormalities with hysteros-
protrudes into the uterine cavity. Its surface is irregular and copy or hysterosonography in asymptomatic postmeno-
partly appears to be nodular or polypoid bulges. It is dull, pausal women. Suspected diagnosis of endometrial lesions
greyish, and somewhat filthy. The endometrial tissues are with TVS was achieved in 77 asymptomatic postmenopausal
fragile, whose borders are not clearly distinguished from the women. The most common diagnosed abnormalities were
surrounding endometrium. The blood vessels become thick- endometrial hyperplasia in TVS (62.33%), endometrial pol-
ened and engorged, and run disorderly, sometimes accompa- yps in both hysterosonography (57.14%) and hysteroscopy
nied by hemorrhage and necrosis (Fig. 8.61h, i). It should be (51.94%). The sensitivity and specificity were 59.7% and
pointed out that hysteroscopy is not omnipotent, and it may 35.5%, respectively, with TVS, 88.8% and 84.4% with sono-
Fig. 8.62 Application of Non-treated Patients

fiber hysteroscopy in
etiological diagnosis of PMB
Transvaginal Sonography (TVS)
Endometrial thickness <4mm Endometrial thickness >4mm Thick endometrium

(double layer) (double layer) but can’t be measured
Follow-up recurrence Fiber hysteroscopy and targeted biopsy
TVS Fiber hyteroscopy Normal Pathological

and targeted biopsy (12 months later) (6 months later)
TVS Fiber hysteroscopy
Patients treated
with estrogen replacement or Tamoxifen
Fiber hysteroscopy and targeted biopsy
Normal Pathological
TVS Alternative
TVS Fiber hysteroscopy

(If bleeding recurs)
6 months later
hysterography, and 91% and 82% with diagnostic hysteros- trial atrophy, anovulatory menstruation, bleeding associated
copy. It was suggested to be effective in diagnosis with with contraception, and uterine adenomyosis, etc.
hysterosonography and hysteroscopy. If the endometrium
was suspected to be abnormal with TVS in asymptomatic Endometrial Atrophy
postmenopausal women, hysterosonography and hysteros- The elderly women are often seen to have AUB caused by
copy should be considered. endometrial atrophy. Endometrial cancer should be ruled out
in them, but the negative results obtained by both cytological
8.2.1.6 Other Pathological Conditions Leading and histopathological examinations are not enough to
to AUB exclude this disorder. The diagnosis of atrophic endome-
Other pathological conditions leading to AUB include endo- trium in elderly women is not easy, by HSG or D&C, during
metrial polyps, submucous myoma, endometrial hyperpla- which there is always hardly any endometrial tissue.
sia, endometrial carcinoma, etc. When patients are of However, simple hysteroscopy can avoid these shortfalls,
child-bearing age, the causes of bleeding are mainly related which can be performed in the outpatient immediately with
to pregnancy. Hysteroscopy can help to find other benign small diameter telescope under local anesthesia. Tinelli et al.
diseases related to the symptoms of AUB, such as endome- carried out a prospective study of 752 postmenopausal
a b
Fig. 8.63 Endometrial atrophy. (a) Intrauterine adhesions at the fundus are visible. (b) Diverticulum is visible
women with AUB and endometrial atrophy. Only three cases rounded by hyperplastic smooth muscle bundles. The
with misdiagnosis of atrophic endometrium under hysteros- disease was not uncommon in the findings on hysterectomy
copy were revealed to be endometrial carcinoma by histo- specimens (frequency 25% to 50%). Cullen pointed out that
pathological examination. In cases of endometrium <4 mm ectopic endometrium was often related with the endome-
in thickness, focal abnormalities often cannot be identified trium which was on the surface of uterine cavity, and HSG
by TVS, but can be detected more accurately by hysteros- or hysteroscopy was helpful in the diagnosis of adenomyo-
copy. Hysteroscopy may provide a definite diagnosis of sis. The direct sign in the diagnosis of adenomyosis by HSG
endometrial atrophy, which is characterized by small uterine is that there are branches outside the contour of the cavity
cavity, difficult uterine distention and possible intrauterine connected to the diverticulum, which appears only when
adhesions (Fig. 8.63a). The general manifestation is that lesions communicate with endometrial cavity (Fig. 8.64a).
there is a decrease in endometrium, which looks like a layer Hysteroscopy can only reveal that the diverticular openings
of transparent film, revealing the intertwined muscle bundle have an appearance of dark or blue concave of varying sizes.
underneath, where may exist invagination, sometimes like a These openings are variable in number and changing in
true diverticulum (Fig. 8.63b). The presence of ecchymosis appearance, and large diverticulum and great numbers of
indicates its bleeding tendency. The glands of the cystic atro- small dots can be seen to be distributed on the endometrial
phic endometrium are covered with a superficial atrophic surface (Fig. 8.64b). The glandular openings may be cov-
epithelium, and some transparent blue-gray spheres may be ered by thick or hyperplastic endometrium, so the optimal
detected under hysteroscope. There are no lesions needing time for examination is just after menstruation. Hysteroscopy
biopsy in the uterine cavity, so drug therapy can be adminis- can also reveal the focus of adenomyosis which is not con-
tered. The endometrial atrophy is rare in fertile women, nected with the superficial endometrium and not too far
which may be caused by hormone therapy and mostly sec- from the cavity, being a transparent blue or brown area.
ondary to the long-term use of progesterone or danazol. Muscle fiber hyperplasia and fibrosis can also lead to the
deformation of the uterine cavity, which can also be sus-
Adenomyosis pected to be adenomyosis (Fig. 8.64c). During the combined
Adenomyosis is also called internal endometriosis, which is examination with hysteroscopy and ultrasonography, under
usually accompanied by hypermenorrhea, but rarely with the intrauterine pressure, the distending fluid and air enter
uterine bleeding, and other symptoms include pelvic con- the ectopic endometrial glands via the openings in the uter-
gestion, dysmenorrhea and enlarged uterus. A pathological ine cavity, and cloudy strong echo in the uterine wall is vis-
feature is the presence of ectopic endometrial island con- ible on ultrasonography, which is most obvious in the
taining stroma and gland in the myometrium, which is sur- anterior wall and also is suggestive of adenomyosis. HSG
a b
c d
Fig. 8.64 (a) Adenomyosis diagnosed by HSG. Diverticulum outside form diverticulum. (c) Adenomyosis. The endometrium has an appear-
the contour of the cavity can be seen. (b) Adenomyosis. The glandular ance of false endometrium. (d) Adenomyosis which is shown as an
openings are on the surface of endometrium, presenting as small pyri- image of “bullhead” by HSG
reveals that the contour of uterine cavity is stiff and forms ily restraining its development. Hysteroscopic diagnosis is
angles, with the cornua expanded and the tubes vertical, another alternative, which can only be applied in the cases
which forms a “bullhead” image and is characterized as when adenomyotic lesions are close to the surface of the
adenomyosis (Fig. 8.64d). Under hysteroscope, tubal ostia endometrium. The visible diverticulum can be treated by
are crack-like and the fundus appears to have trabecular electrocoagulation or laser vaporization, but a more radical
structure due to muscle fiber hyperplasia, which is also a method is to remove the whole endometrium, but lesions in
sign of adenomyosis. The treatment with ovarian inhibitors the deep layer cannot be removed, so hysterectomy is still
of GnRH analogs or danazol may have effects of temporar- the only option for severe cases.
AUB Caused by Contraception or Hormone Therapy lium atrophy (Fig. 8.66a). These changes occur either in the
Insertion of IUD often causes increased menstruation, and endometrium itself or in the polyps which protrude from the
also leads to intermenstrual bleeding, excessive menstrual endometrium (Fig. 8.66b–f).
bleeding, and prolonged menstruation, and can induce Endometrial polyps are the most common endometrial
complications as well (Fig. 8.65). AUB can be a forerunner pathology in postmenopausal women taking tamoxifen.
of organic diseases, which alerts the patient to undergo intra- Cohen et al. reported that up to 3% of these polyps were
uterine inspection. Prior to diagnostic hysteroscopy, IUD malignant. They conducted a comparison between 54 cases
should be left in situ rather than be blindly removed, so that with endometrial polyps resected by hysteroscopy (Group I)
if no organic diseases are found by hysteroscopy, other rea- and 210 cases with no endometrial polyps detected by hys-
sons such as translocation or incarceration of the IUDs could teroscopy (Group II) in postmenopausal women with breast
be established. Such diagnosis would be missed if IUD is carcinoma and tamoxifen treatment. The results showed that
removed first. The removal of IUD under direct vision can compared with Group II, the patients’ ages in group I were
avoid the shortcomings of blind removal including failure in significantly older (P = 0.0162), the duration of having breast
its removal or fracture of the IUD, and even perforation of disease was significantly longer (P = 0.0026), and the body
the uterus. In some cases, IUD is in good place and there are weight was significantly heavier (P = 0.0364). Therefore it
no intrauterine abnormalities. was believed that these three factors and a thicker endome-
Patients taking oral contraceptives may have break- trium may contribute to higher risks of development of endo-
through bleeding, if AUB still exists after regulation of the metrial carcinoma in these patients.
dosage, organic lesions should be excluded before other con-
traceptive measures are taken instead. Hysteroscopy is the Dysfunctional Uterine Bleeding (DUB)
most rapid and safe method to rule out any organic lesions. DUB may be diagnosed if an IUD is not placed; no contra-
18–40% of the patients with uterine hemorrhage caused ceptives taken; or no intrauterine lesions found. The confir-
by HRT have focal endometrial lesions. Long-term use of mation of the diagnosis depends on the patients’ age.
TMX after radical mastectomy may lead to asymptomatic For AUB in any gynecological field, hysteroscopy is the
endometrial changes, which increase the risk of endometrial key examination method. In a woman’s life, abrupt uterine
hyperplasia and endometrial polyps, and there are also cases bleeding occurs rarely, and often with no serious conse-
found with endometrial cancer. It was reported by Mourits quences. However, it can also be a signal to a serious disease,
et al. and Anteby et al. that, Tamoxifen could induce specific which requires immediate diagnosis. Regrettably, lack of
endometrial changes consisting of cystically dilated glands attention and only simple symptomatic medication without
with periglandular stroma gathering and overlying epithe- any examination may lose opportunities for early diagnosis
and treatment.
8.2.2 Infertility
More than 100 years ago, when hysteroscopy was still at

infancy stage, it was an important method to diagnose and
treat some diseases causing infertility. The instruments in
use include panoramic hysteroscope, contact hysteroscope,
micro-hysteroscope, and flexible hysteroscope, each of
which has its own advantages and disadvantages.
Hysteroscopic examination conducted in infertile women
aims to assess whether anatomies of reproductive organs are
normal or not and also to check the patency of fallopian
tubes. Hucke et al. reported that different grades of intrauter-
ine abnormalities were detected by hysteroscopy in 20% of
infertile patients, with uterine malformations the most com-
mon disorder. Pansky et al. reported that intrauterine abnor-
malities were visible under hysteroscopy in 30% of 221
women who have either primary or secondary infertility,
with no significant difference between groups of primary and
secondary infertility. Thus diagnostic hysteroscopy should
Fig. 8.65 Intrauterine device be done as a routine method.
In the diagnosis of infertility, hysteroscopy cannot be a more clearly than hysteroscopy, and is also superior in the
substitute for HSG, and hysteroscopy and HSG are comple- detection of adenomyosis. Finally, HSG can provide the
mentary rather than competitive to each other. Firstly, HSG information requiring to change the therapy. For example, if
is a relatively cheap method, which can provide important a hydrosalpinx is found by HSG to be too large for recon-
information about the cervical canal, cervical internal os, struction operation, In Vitro Fertilization and Embryo
uterine cavity, and full length of the fallopian tubes. The con- Transfer (IVF/ET) should be considered instead. Moreover,
ditions of fallopian tubes are very important to infertility. bilateral tubal obstruction caused by pelvic tuberculosis can
Secondly, HSG can outline the contours of the uterine cavity only be detected by traditional radiology.
a b
c d
Fig. 8.66 (a) Cystic atrophy of the endometrium and hyperplasia in breast cancer. (b) An endometrial polyp is seen under hysteroscope. (c)
blood vessels are visible in a woman with bleeding after TMX treat- The blood vessels on the surface of the polyp. (d) The endometrium. (e)
ment. An endometrial polyp in a woman who has had menopause for Electroresection of the endometrium and polyp. (f) The resected polyp
24 years and taken TMX for 2 years after radical correction for right tissues
e f
Table 8.5 Comparison between hysteroscopy and HSG peutic value, very suitable for checking the cervical canal
Hysteroscopy HSG and uterine cavity so as to discover lesions interfering with
Can directly inspect the May outline of the uterine cavity embryo implantation and (or) development.
uterine cavity with contrast medium The majority of infertile women are nulliparous, and they
Can confirm the diagnosis of Can only make a provisional have higher incidence of genital malformations and anxiety
“tumors” diagnosis compared with the normal population, so they often cannot
Can precisely locate the Cannot precisely locate the lesion
tolerate hysteroscopic operation. With the introduction of
lesions
Can proceed to do the Unable to treat lesions miniature hysteroscope or fiber hysteroscope in recent years,
operative hysteroscopy noninvasive insertion, fluid uterine distension and no require-
Can only examine the uterus May examine the uterus and ment of anesthesia make it possible in an outpatient setting,
fallopian tube as well leading to better compliance of the patients.
Moderate cost Low cost Common intrauterine lesions causing infertility are sub-
No radiation Small quantity of radiation
mucosal myoma, intrauterine adhesions, endometrial polyps,
congenital uterine malformation, intrauterine foreign body,
A comparison between HSG and hysteroscopy is made in and obstructed fallopian tubal ostia, etc.
Table 8.5, and it can be concluded from the table that hyster-
oscopy is significantly superior to HSG. However, as a 8.2.2.1 Indications of Hysteroscopy for Infertile
screening method, HSG is low in cost and can provide some Women
useful information, therefore it should not be given up. 1. AUB.
Some authors have suggested that hysteroscopy can detect 2. History of complex surgeries of the uterus or the cavity.
lesions in infertile patients even with normal HSG. If a recent 3. Repeated pregnancy failures.
HSG reveals a normal endometrial cavity (including that in 4. TVS reveals intrauterine abnormalities.
the early filling stage with the uterine axis parallel to the film 5. HSG reveals uterine abnormalities or filling defects.
plane), hysteroscopy may not be needed. If HSG shows 6. Hysteroscopy has not been previously performed, but it
intrauterine filling defect, hysteroscopy needs to be done to can be done simultaneously with laparoscopy.
determine the presence of the lesion and its nature. 7. Unexplained Infertility.
Hysteroscopy is an important means in the diagnosis of 8. Patients who has not previously had hysteroscopy and
causes of infertility. Meanwhile, it is also of important thera- failed to conceive after IVF-ET.
8.2.2.2 Infertility Factors Revealed by Hysteroscopy is superior in revealing intrauterine adhe-

Hysteroscopic Examination sions to any other method used in the past but it can only
display the uterine cavity below the adhesive level. However,
Uterine Myoma when the joint examination of hysteroscopy and ultrasonog-
The impact of uterine myomas on infertility is still not very raphy is performed, ultrasonography can also show the con-
clear, but intrauterine myomas can lead to deformation of ditions of uterine cavity above the adhesive level. Under the
uterine cavity, and may interfere with fertility similar to a guidance of ultrasonography, it is easier for the hysteroscope
foreign bodies. Histological studies showed that intramural to go through the narrow adhesive sites so that the inspection
myomas and submucosal myomas can change the structure of the cavity above the adhesion level can be continued.
of the endometrium and myometrium, but subserosal myo-
mas may not affect fertility, most of which do not have Endometrial Polyps
symptoms. Hysteroscopy plays important roles in determin- Endometrial polyps may or may not cause infertility or
ing the location of myomas (Fig. 8.67) and the necessity for recurrent pregnancy loss, but its exact cause is unknown.
surgery and choice of surgical modality. The influence of the Cytogenetics may play an important role. Polyps may induce
location of the myomas and increased reactive vessels on bleeding during, before and after the menstrual period, but
infertility which is visible through hysteroscope remains to the majority of them are asymptomatic, so it often cannot be
be studied. diagnosed by HSG (Table 8.6). In addition, a small polyp
may not be detected by ultrasonography scanning but hyster-
Intrauterine Adhesion oscopy can recognize it clearly, determine its nature, decide
Intrauterine adhesion is a common problem in most patients on its therapy or remove it at the same time (Fig. 8.68a–c).
with secondary infertility. The reason for intrauterine adhe- Compared with curettage, the polyp tissues removed by hys-
sions is trauma and infection, which are more common after teroscopy is relatively more complete and there is also no
missed abortion, D&C, cesarean delivery or intrauterine trauma to the endometrium.
operation. The patients with complete uterine occlusion may
suffer from amenorrhea and secondary infertility. However, Congenital Uterine Malformations
the mechanism of secondary infertility in patients with The incidence of congenital uterine malformations is diffi-
incomplete uterine occlusion is still not clear, and may be cult to determine, because not all malformations have symp-
caused by decreased area of functional endometrium in uter- toms or cause infertility. The reported incidence varies
ine cavity or increased functional disorder of endometrial substantially, from 0.2% to 10%, the possible reason may be
vasculature. the difference in the subjects studied or the explanations for
different lesions given by scholars.
The uterine septum plays an important role in infertility,
including complete and incomplete uterine septum. For
incomplete septum under hysteroscope, it can be seen that
bilateral uterine cornua are completely separated (Fig. 8.69),
on top of which the tubal ostia are visible. The septum of a
complete septate uterus begins from the fundus, extends
directly to the internal os or lower, and divides the uterus into
two cavities, but sometimes the septum has an fissure in the
cervical canal or the internal os so that both sides of the uter-
ine cavity can communicate. Combined hysteroscopy and
laparoscopy can exclude the bicornuate uterus, didelphic
Table 8.6 Detection rate of endometrial polyps with D & C

Missed
Diagnosis diagnosis
Research No. of cases (%) (%)
Bibbo et al.(1982) 840 83 17
(D&C/ hysterectomy)
Burnett (1964) (D&C/ 1298 (121, 53 47
hysterectomy) 9.3%with
polyps)
Valle (1981) 553 (179 with 100/10 0/90
Fig. 8.67 Submucosal myoma in the right uterine cornu (hysteroscopy /D&C) polyps)
a b
Fig. 8.68 (a–c) Endometrial polyps
uterus, and unicornuate uterus through laparoscopy. Uterine Acquired uterine abnormalities were found significantly
septum may induce repeated miscarriage more than infertil- higher in control group than those in study group (32% and
ity. Valli et al. analyzed the prevalence of different anatomic 9%, respectively). There were no significant differences
abnormalities in women with recurrent pregnancy loss. This observed in frequency of intrauterine adhesions between the
study included 344 patients with recurrent pregnancy loss, study group and the control group (4% and 2%). It was
and 922 women with AUB as control group. In study group, believed that major mullerian uterine abnormalities were
uterine mullerian abnormalities were found significantly related to recurrent pregnancy loss, and minor uterine abnor-
more than those in control group (32% and 6%, respectively). malities might increase the risk of recurrent miscarriage.
Fig. 8.69 Incomplete uterine septum Fig. 8.70 Placental remnants under hysteroscope
Infantile uterus has a normal uterine cavity with a ratio of

1:3 between the uterine body and cervix, which stays in the 8.2.2.3 Hysteroscopic Tubal Catheterization
status of a young girl. Its causes of infertility are the simulta- and Hydrotubation
neous presence of functional insufficiency of ovaries instead Salazar et al. reported that one out of five couples had a tran-
of uterine anomalies. T-shaped uterus is rare, and it is an off- sitory problem of infertility at the childbearing age. The most
spring deformity induced by diethylstilbestrol which is taken frequent cause is the tubo-ovarian pathological changes, in
by pregnant women. There were two million to three million which proximal obstruction takes up 25–30%. Unfortunately,
pregnant women who took diethylstilbestrol from 1941 to the conventional method in the examination of tubal patency,
1971, so it would continue to occur after 2000. such as HSG, often cannot differentiate between an insuffi-
cient filling of the tubes, fallopian tubal spasm and tubal
Intrauterine Foreign Bodies obstruction. Catheterization under hysteroscopic guidance
Occasionally, during hysteroscopic examination of the uter- (Figs. 8.71a–d and 8.72a–d) and direct observation of dye
ine cavity, some intrauterine foreign bodies can be found, tubal patency by laparoscopy are extremely useful in the
and can be removed at the same time. Among these foreign diagnosis of tubal patency or in the determination of partial
bodies, IUD fragments are the most common, fetal bones or total proximal tubal disease, and differentiation can also
and placental remnants are only occasionally seen (Fig. 8.70). be made at the same time.
Under the guidance and intervention of ultrasonography, it is Hysteroscopic tubal catheterization for proximal tubal
relatively safe to take them out, and also there are more occlusion is not only diagnostic but also therapeutic, and
chances of a complete removal. superior to HSG. Generally, a #3Fr rigid hollow plastic
catheter is used and its tip is inserted via the operational
Chronic Endometritis channel of hysteroscope into the fallopian tubal ostia and
Chronic endometritis has been related to infertility and then pushed in so that interstitial regional obstruction may
recurrent pregnancy loss. It is usually asymptomatic, and the be eliminated. The catheter may be inserted 1–1.5 cm, and
diagnosis is rarely clinically suspected. Polisseni et al. per- then the diluted methylene blue (MB) liquid is injected to
formed a prospective study to evaluate the role of diagnostic the lumen. The degree of tubal patency may be judged
hysteroscopy for this disease, with sensitivity 16.7%, speci- according to the pressure and speed of water injection,
ficity 93.2%, positive predictive value 25%, and negative whether there is liquid overflow, and whether there is
predictive value 89.1%. return flow after suspension of water injection. In combi-
a b
c d
Fig. 8.71 Hysteroscopic tubal catheterization. (a) Before the hydrotubation. (b) During the hydrotubation. (c) Before the hydrotubation. (d)
During the hydrotubation
nation with laparoscopy, it can be judged according to the technique is to dilate with balloon after the tubal patency is
flow rate of methylene blue through the tubal fimbria achieved with guide wire. As the technique of hystero-
(Fig. 8.73a, b). When the distal end of fallopian tube is scopic catheterization for patency is very successful, the
being reopened, the stainless steel wire should be placed transplantation of gametes and embryos under the guid-
inside the catheter under laparoscopic monitoring. Kerin’s ance of hysteroscopy has also been well developed.
a b
c d
Fig. 8.72 (a) Left tubal ostium under hysteroscope. (b) Hysteroscopic catheterization under direct vision. (c) Instillation of methylene blue liquid.
The blue-stained image indicates the tubal impatency. (d) Image after being irrigated with distending fluid
8.2.2.4 Endometrial Changes in Patients Vascular structural anomaly is another lesion that can
with Infertility only be seen by hysteroscope, which plays an important role
The endometrial changes in patients with infertility reported in reproduction. Increased endometrial blood vessels are
by Leuven institute are seen in Table 8.7. Except that hyster- common in endometritis, submucous myoma, and uterine
oscopy can be performed in the diagnosis of the above obvi- intramural myomas, but it may exist alone as well. The defi-
ous major lesions, the miniature hysteroscopy can also often nition of increased endometrial blood vessels is an obvious
detect some tiny endometrial lesions (Table 8.8), such as increase in the amount of blood vessels at its proliferative
moderate and significant endometrial swelling, which may phase or that the endometrium grows red, on which the white
indicate hormonal imbalance. glandular openings are set, forming a typical strawberry
a b
Fig. 8.73 (a) Left tubal fimbria is revealed under laparoscope before hysteroscopic catheterization and hydrotubation. (b) Methylene blue liquid
can be seen flowing out through the left tubal fimbria under laparoscope during hysteroscopic catheterization and hydrotubation
Table 8.7 Endometrial changes by hysteroscopy in infertile patients cases with failed IVF were found to have intrauterine lesions
by hysteroscopy. Feghali et al. conducted a retrospective
No. of gynecological No. of infertile
Item patients (%) patients (%) analysis of the findings of a diagnostic hysteroscopy prior to
Total cases 4204 530 in vitro fertilization. Intrauterine abnormalities were
Abnormal 1189 (28.3) 151 (28.5) observed in 45% of hysteroscopies. Hysteroscopy prior to
Congenial 70 (1.7) 70 (13.2) IVF should be performed as a regular investigation that could
Acquired 455 (10.8) 21 (4.0) improve the pregnancy rate.
Minimal 664 (15.8) 60 (11.3)
endometrial lesions
8.2.3 Uterine Malformations

Table 8.8 Minimal endometrial changes in infertile patients by minia-
ture hysteroscopy The means for modern diagnosis of uterine malformations
No. of gynecological No. of infertile include hysteroscopy, transabdominal ultrasonography,
Item patients (%) patients (%) TVS, SHSG, CT, MRI, and laparoscopy, etc. These simple,
Minimal endometrial 441 (66.5) 32 (53.3) safe, and effective methods can help physicians to have a bet-
lesions ter understanding of the anatomical features of uterine
Endometrial 70 (10.5) 14 (23.3) malformations.
adhesions
Increased blood 52 (7.8) 9 (15)
vessels 8.2.3.1 Formation and Classification
Necrosis 28 (4.2) 4 (6.7) of the Uterine Malformations
Diffused polypoid 60 (9) 1 (1.7) During the embryonic phase, if the development of the uterus
changes is disturbed by some internal or external factors, which leads
Others 13 (2) 0 (0) to the hypoplasia or fuse barriers of Mullerian ducts, various
types of congenital uterine malformation would result.
Nowadays, clinically and commonly used classification
image. There is hardly any diagnostic value in either micro- of congenital uterine malformation is the classification pub-
biological or histological examinations for such patients. lished by American Fertility Society (AFS) in 1988, which
Miniature hysteroscopy plays a key role in evaluating the included aplasia or dysplasia of Mullerian ducts, unicornuate
effects of different treatment modalities in order to maintain uterus, uterus duplex, bicornuate uterus, septate uterus, arcu-
a normal intrauterine environment. Hysteroscopy is accurate ate uterus, T-shaped uterus, etc. (Table 8.9). Recently,
and effective in the diagnosis of intrauterine lesions in European Society of Human Reproduction and Embryology
patients with infertility, and can be used as a means of first (ESHRE)and European Society for Gynaecological
line screening test for infertile patients. Hysteroscopy has an Endoscopy (ESGE)jointly published a new classification of
important practical value for IVF. Herrera found that 38% of female genital malformations, which was mainly based on
Table 8.9 AFS classification of Mullerian duct anomalies Table 8.10 Scheme for ESHRE/ESGE classification of female genital
tract anomalies. Uterus
Class I Uterine agenesis/ a. Vaginal
uterine hypoplasia b. Cervical Cervix vagina
c. Fundal U0 normal uterus C0 V0 normal
d. Tubal normal vagina
e. Combined cervix
Class Unicornuate uterus a. Communicating rudimentary U1 a. T-shaped C1 V1 longitudinal
II horn dysmorphic b. Infantilis septate non-obstructing
b. Non-communicating Uterus c. Others cervix vaginal septum
rudimentary horn U2 septate a. Partial C2 double V2 longitudinal
c. Rudimentary horn without uterus b. Complete cervix obstructing
endometrial cavity vaginal septum
d. no horn
U3 a. Partial C3 V3 transverse
Class Uterus didelphys bicorporeal b. Complete unilateral vaginal septum
III Uterus c. Bicorporeal Cervical and/or
Class Bicornuate uterus a. Complete division septate aplasia imperforate
IV b. Partial division hymen
Class Septate uterus a. Complete division U4 a. With rudimentary C4 V4 vaginal
V b. Partial division hemi-uterus cavity cervical aplasia
Class Arcuate uterus (comminicating aplasia
VI or not horn)
Class In utero diethylstilbestrol (DES) exposure (T-shaped b,. Without
VII uterus)_ rudimentary
cavity
(horn without
the anatomic characteristics, classified the uterine, cervical, cavity/no horn)
and vaginal anomalies independently and then made a com- U5 aplastic a. With rudimentary
cavity
prehensive evaluation (Table 8.10). (bi- or unilateral
horn)
Congenital Uterine Anomalies b. Without
U0: normal uterus. For a normal uterus, the interostial line rudimentary
cavity
between both tubal orifice is either straight or curved, and the (bi- or unilateral
internal indentation at the midline of the fundus is less than uterine aplasia)
50% of the thickness of the uterine wall. U6 unclassified malformations
U1: Dysmorphic Uterus. For a dysmorphic uterus, the
uterine outline is normal but the shape of the cavity is abnor-
mal. In addition, septate uterus is not included in this class. U2a: partial septate uterus. The main characteristic is
Generally the uterus is smaller than a normal uterus, and is that the septum extends from the fundus to the cavity which
further divided into three sub-categories. ends above the internal os and divides the uterine cavity
U1a: T-shaped uterus. The main characteristic is a narrow partly.
cavity with bilateral walls thickening. The ratio of the corpus U2b: complete septate uterus. The main characteristic is
to the cervix is 2:1. that the septum extends from the fundus to the internal os
U1b: infantile uterus. The main characteristic is a narrow and divides the uterine cavity totally. These patients may
cavity without the thickening of bilateral walls. The ratio of have or have not cervical and/or vaginal deformities.
the corpus to the cervix is 1:2. U3: bicorporeal uterus. It is caused by fusion defects of
U1c: other dysmorphic uterus. It includes all minor deformi- bilateral Mullerian ducts and characterized by abnormal fun-
ties of the uterine cavity with an inner indentation at the midline dal outline. The external fundal indentation exceeds 50% of
of the fundus less than 50% of the thickness of the uterine wall. the thickness of the uterine wall, which separate both cornua
U2: Septate Uterus. It is caused by failure in absorption of apart. The inner fundus at the midline protrudes to the cavity
midline septum with normal development and fusion of and separates the cavity, which is similar to septate uterus. It
bilateral Mullerian ducts. The definition of a septate is a nor- is further divided into three sub-categories.
mal outline of the uterus with an inner indentation at the mid- U3a: partial bicorporeal uterus. Its characteristic is that
line of the fundus more than 50% of the thickness of the the external fundal indentation partly divides the uterus
uterine wall. It is subdivided into two categories. above the internal os.
U3b: complete bicorporeal uterus. Its characteristic is that fully separated or partially fused. It is classified as U3b/C2
the external fundal indentation completely divides the uterus when a double cervix co-exists with a complete bicorporeal
up to the level of the cervix. uterus.
U3c: bicorporeal septate uterus. It is caused by an absorp- C3: unilateral cervical aplasia. It includes the cervices
tion defect being combined with a septum fusion defect. The with unilateral development and manifests as only unilateral
thickness of the fundus at the midline is more than 150% of cervical development with the contralateral part aplasia or
that of the uterine walls. In these patients, the septum com- absent.
ponent could be resected by hysteroscopy. C4: complete cervical aplasia. It includes all cases with
U4: Hemi-uterus. It is caused by normal development of absolute absence or severe defects of cervical tissues.
unilateral uterus, and absence or incomplete formation of
contralateral uterus. It includes all unilateral formed uterus Co-existent Congenital Vaginal Anomalies
which fully develops a functional cavity, with the contralat- V0: normal vagina. It includes all normal developed
eral uterus dysplasia or absent. Hemi-uterus is further divided vaginas.
into two sub-categories. V1: longitudinal non-obstructing vaginal septum.
U4a: hemi-uterus with a rudimentary cavity. Its character- V2: longitudinal obstructing vaginal septum.
istic is that a rudimentary horn with partial functional cavity V3: transverse vaginal septum and/or imperforate hymen.
lies contralaterally, which does or does not communicate the V4: vaginal aplasia. It includes all cases with complete or
hemi-uterus. The functional endometrium in contralateral partial vaginal aplasia.
cavity has some clinical values because it can result in hema-
tocele or ectopic pregnancy, which are indications of laparo- 8.2.3.2 Clinical Manifestations of Uterine
scopic resection. Malformation
U4b: hemi-uterus without a rudimentary cavity. Its char- A patient with congenital absence of uterus or primordial
acteristic is that the contralateral uterus is absent or a solid uterus will not have menstruations and has no probability of
horn without any cavity. conception during her whole life. A patient who has aplastic
U5: Aplastic uterus. It includes all uteri with development uterus and functional endometrium may have oligomenor-
defects, and its characteristic is absent of the formation of rhea, and periodic abdominal pain or hematocele if the outlet
bilateral or unilateral uterus; in some cases, both or unilateral for discharging the menstrual blood is obstructed. In patients
rudimentary uterine cavity could be found; sometimes a who have uterine malformations including hemi-uterus, dou-
solid uterus remnant without any cavity could be seen. ble uterus, bicorporeal uterus and septate uterus, some com-
Patients with aplastic uterus can also have co-existent defects plications could happen, such as miscarriage and premature
such as vaginal aplasia (Mayer-Rokitansky-Küster-Hauser delivery, oligomenorrhea and infertility, midtrimester loss,
syndrome, MRKH syndrome). Aplastic uterus is subdivided abnormal fetal position, fetal abnormality, premature rupture
into two categories. of fetal membrane, uterine inertia, postpartum hemorrhage,
U5a: aplastic uterus with rudimentary cavity. Its charac- retained placenta, uterine rupture, etc. Patients with uterine
teristic is bilateral or unilateral functional horn. malformations may have other co-existing organ aplasia,
U5b: aplastic uterus without rudimentary cavity. Its char- such as malformation of the urinary system.
acteristic is uterine remnants or full aplasia.
U6: unclassified uterus. It includes all uteri which could 8.2.3.3 Diagnosis of Uterine Malformation
not be allocated to one of above groups, and are caused by Uterine malformation can be presumptively diagnosed via
formation, fusion or absorption defects occurring during nor- routine gynecological examination, TVS, 3-D ultrasonogra-
mal embryological development, such as rare uterine malfor- phy, HSG and hysteroscopy, etc. The confirmation of the
mations, mini anomalies or co-existing deformations. diagnosis can be achieved by joint investigation of hysteros-
copy and laparoscopy in indecisive cases.
Co-existent Congenital Cervical Anomalies
C0: normal cervix. It includes all normal developed 1. Routine gynecological examination: It can reveal vaginal
cervices. septum, double cervix, and uterine malformations with
C1: septate cervix. It includes the cervices with septa obvious changes in shapes such as double uterus, bicor-
absorption defects and manifests as a cervical septum in a poreal uterus, and rudimentary uterus.
normal round cervix. 2. Gynecological ultrasonography: With transabdominal or
C2: double cervix. It includes the cervices with fusion transvaginal ultrasonography, and 3-D ultrasonography,
defects and manifests as two round cervices, which could be both the sizes and the outlines of the uterus, and both the
echo and the shapes of the endometrium can be observed, 8.2.3.4 Role of Hysteroscopy in Diagnosis
which could achieve a high accuracy for diagnosing uter- of Uterine Malformation
ine malformations. B-mode ultrasonography can deduce The hysteroscope can be inserted directly into the cervical
the contour of the uterus and the shape of the cavity canal and the cavity to observe the anatomic changes of the
through transverse and longitudinal scanning, and mea- cervix and the cavity, so that it can help to determine the
sure each dimension of the uterus, which is a commonly types of uterine malformations. The main observations of
used investigation for diagnosing the uterine malforma- hysteroscopy are:
tions. 3-D ultrasonography can get a three-dimensional
image of the uterus, and directly visualize the outline of 1. The characteristic of the fundus. It can observe the degree
the uterus, the thickness of the uterine wall and the shape of indentation of the fundus to the cavity, and makes mea-
of the cavity, accurately measure the thickness of the fun- surement under hysteroscope. Taking the connection line
dal wall, the depth of the external indentation of the fun- between bilateral tubal orifice as the base line, the inden-
dus, and the angles between bilateral endometrium, tation of the fundus can be measured which can help to
which have a very high sensitivity and accuracy for diag- diagnose the type of uterine malformation. Generally, it
nosing uterine malformations (Fig. 8.74). should be a saddle form uterus if the length is less than
3. HSG: HSG can reveal the location, shape, and size of 1.5 cm, and should be a septate uterus if it is more than
both the cavity and the tubes. The image of a normal cav- 1.5 cm.
ity is an inverted triangle. It might be a double uterus or 2. Intrauterine septum. It should observe the length and the
complete septate uterus if HSG reveals two cavities; and width of the septum, the location of the septum and its
might be a unicornuate uterus if it reveals a unilateral ends, the symmetry of bilateral cavities, and measure
long and narrow cavity; and might be a T-shaped uterus if the length of the septum; identify whether there is a sep-
it reveals a “T” shape cavity. tum in cervical canal, and whether there is communica-
4. Magnetic resonance imaging (MRI): MRI can reveal the tion between two cavities. In complete septate uterus, a
shapes of the uterus and the cavity, distinguish different communicating of two cavities can always be found
types of uterine malformations, make definite diagnosis above the internal os where the septum is thin. During
and has a high resolution. Furthermore, it can evaluate hysteroscopy, when looking forward, it is like partial
whether a malformation of urinary system co-exists, septum, but when looking backward, cervical septum
which has a high accuracy. can be detected.
5. Laparoscopic examination: Laparoscopy can identify the 3. The shape of the uterus. In septate, bicornuate, unicornu-
shape of the uterine serosa, especially the fundus, and ate and Robert uterus, bilateral or unilateral cavity is long
accurately determine the types of the uterine malforma- and narrow, with the tubal orifice seen at its top. In a
tion when combined with hysteroscopy (Fig. 8.75a–d). T-shaped uterus, the cavity is “T” shaped, with its upper
a b
Fig. 8.74 (a) Image of bicornuate uterus under B-ultrasonography. (b) Under 3-D ultrasonography, the middle and lower parts of the cavity is
narrowed with an IUD visible. Suggestion: T-shaped uterus?
a b
c d
Fig. 8.75 (a) Uterus duplex under laparoscope. (b) Septate uterus under laparoscope. (c) Robert uterus under laparoscope. (d) Right unicornuate
uterus with left rudimentary horn under laparoscope
part narrow, fundus arched, and bilateral walls thickened 8.2.4.1 The Embedment or Residual Intrauterine
at mid and lower parts of the cavity, which forms a cylin- Contraceptive Device (IUD)
drical cavity (Fig. 8.76). IUD embedment (Fig. 8.78a–i), IUD fragments residue
(Fig. 8.79a–d), and reversible tubal contraceptive device
residual are the most common intrauterine foreign bodies.
8.2.4 Intrauterine Foreign Bodies Olaore et al. reported a case who had adhesiolysis and inser-
tion of IUD due to Asherman’s syndrome and was seen with
Intrauterine foreign bodies can be detected during ultraso- intravesical translocation of the IUD 1 year later, which was
nography scanning or hysteroscopy. Ultrasonography scan- removed using bladder biopsy forceps under direct vision of
ning may reveal abnormal echo or space-occupying lesions cystoscopy.
in the uterine cavity, which can be defined and located by
hysteroscopy, and whether they can be removed hystero- 8.2.4.2 Residual Fetal Bones or Osseous
scopically can be determined. An attempt can also be made Metaplasia of the Endometrium
to hook them out under the guidance of hysteroscope Fetal bone residue after abortion (Fig. 8.80a–c) is a rare
(Fig. 8.77a–d). complication, which is more common in termination of
second- trimester pregnancy, often causes bleeding or

secondary infertility, and sometimes may occupy most of
the uterine cavity. It is also difficult to be detected by
HSG, but more readily by hysteroscopy. Little fetal bone
residue needs to be differentiated from osseous metapla-
sia of the endometrium, and the latter may also cause
infertility.
8.2.4.3 Residual Pregnancy Tissue

Placental remnants, induced by delayed miscarriage,
incomplete miscarriage, adherent placenta, and placenta
percreta, remain inside the uterine cavity, which can cause
intrauterine adhesion, amenorrhea or irregular bleeding. If
the adhesion is too severe, the residual pregnant tissue may
not be detected or completely scraped by D&C. Hysteroscopy
can be done not only to make the diagnosis but also in
removal or resection of the pregnant tissues with the elec-
tric wire loop under the guidance of B-ultrasonography.
The tissues removed should be sent for histopathologic
examination (Fig. 8.81a, b).
Fig. 8.76 Partial septate uterus under hysteroscope
a b
Fig. 8.77 (a) A metal ring under hysteroscope, which has been placed has been taking nilestriol for 2 weeks. (b) The hook is placed for
in uterine cavity for 16 years in a patient who reached menopause removal of IUD under hysteroscopic direct vision. (c) Removal of IUD.
3 years ago, the IUD could not be removed 1 year ago and the patient (d) Removed IUD
c d
a b
Fig. 8.78 (a–e) Embedded IUD. (f) IUD is put around the myoma. (g) five earlier attempts to remove the IUD had all failed. (h) The left side
A metal ring under hysteroscope, which has been placed in uterine cav- of IUD is embedded into the left uterine wall. (i) The right side of IUD
ity for 22 years in a patient who has been in menopause for 12 years and is embedded into the right uterine wall
c d
e f

g h

a b
c d
Fig. 8.79 (a–c) Residual IUD fragments. (d) A hysteroscopic view of a residual IUD, embedded in the left fundus of uterus in a patient with
menopause for 1 year and 2 weeks after the removal of IUD
a b
Fig. 8.80 (a–c) Residual fetal bones under hysteroscope
a b
Fig. 8.81 (a, b) Placental remnants under hysteroscope

8.2.4.4 Ruptured Cervical Dilator or Residual Society of Hysteroscopy, that is, filmy adhesive areas in the
Laminaria Tent uterine cavity.
They are quite rare. A cervical dilator or laminaria tent is Usually, injury occurs 1 to 4 weeks after full-term deliv-
placed before hysteroscopic surgery or induced abortion in ery, premature birth, and miscarriages when curettage is
order to soften and dilate the cervix. Sometimes it may be needed due to large amounts of vaginal bleeding. At this
broken inside the cervix when removed, and then fall back time, the endometrium is so thin that any injury may be
into the uterine cavity. exposed or cause damage to the endometrial basal layer,
resulting in fusion of opposite uterine walls and formation of
8.2.4.5 Residual Non-absorbable Sutures continuously existent trabecula (Fig. 8.83), thus the symme-
Following Cesarean Section try of uterine cavity is disrupted. Occasionally transabdomi-
The non-absorbable silk thread had been used to suture at nal hysterotomy or metroplasty may lead to intrauterine
Cesarean section previously. Sometimes the residua of thread adhesions, but such kind of adhesions is generally caused by
or thread knot can be seen at the level of internal cervical os staggered sutures rather than real healing of the denude sur-
during hysteroscopy (Fig. 8.82). These foreign bodies may face of uterine myometrium after childbirth or suction
cause endometrial bleeding or infection. abortion.
Clinically there were various widely used classification
systems for intrauterine adhesions. In 1978, March made
8.2.5 Intrauterine Adhesions the classification of IUA based on the hysteroscopic find-
ings, which is given in Table 8.11. In 1988, according to
8.2.5.1 Formation and Classification the observations on HSG and at hysteroscopy, Valle and
of Intrauterine Adhesions Sciarra classified intrauterine adhesions into three types
Intrauterine adhesion (IUA) is induced by scarring following (mild, moderate, severe) basing on their severity
injury to gravid uterus or uterus shortly after pregnancy, 90% (Table 8.12). In the same year, AFS produced a classifica-
of which is caused by curettage. Salzani et al. studied 109 tion of IUA basing on HSG findings, hysteroscopic out-
cases who had been subjected to uterine curettage following comes, and pregnancy prognosis, which is given in
abortion and underwent diagnostic hysteroscopy 3 to Table 8.13. The classification published by ESGE in 1988
12 months later. IUA was found in 37.6% of patients, with is given in Table 8.14.
56.1% grade I according to the classification of the European
Fig. 8.83 Formation of trabecula in a case with intrauterine

Fig. 8.82 Residual silk thread 15 months after Cesarean section adhesions
Table 8.11 March’s classification of IUA

Tubal ostia and upper segment of the
Grades cavity involvement Adhesions cavity
Mild <1/4 Filmy or thin Light or clearly visible
Moderate 1/4 ~ 3/4 No uterine wall adhered Partly occluded
Severe >3/4 Uterine wall adhered or adhesive Occluded
bands thickened
Table 8.12 Valle and Sciarra classification of IUA

Grades Adhesions and endometrium Cavity
Mild Filmy adhesions composed of basal layer endometrium, focal –
or extensive
Moderate Fibromuscular adhesions, thickened and covered with Partially or totally occluded
endometrium
Severe Connective adhesive tissues with no endometrial tissue Partially or totally occluded
Table 8.13 AFS prognosis classification of IUA

Characteristics Score Hysteroscopy score HSG score
Cavity involvement <1/3 1
1/3–2/3 2
>2/3 4
Type of adhesions Filmy 1 0 or 4
Filmy and dense 2
Dense 4
Menstrual pattern Normal 0
Hypomenorrhea 2
Amenorrhea 4
Total score /
Prognostic classification: Stage I (Mild: 1–4 scores); Stage II (Moderate: 5–8 scores); Stage III (Severe: 9–12 scores)
Table 8.14 ESGE classification of IUA.(Under hysteroscope)

Grade Adhesions Uterine cavity
I Thin or filmy adhesions easily ruptured by hysteroscope Cornual areas normal
sheath alone
II Singular dense adhesion cannot be ruptured by The adhesion connecting separate areas of the
hysteroscope sheath alone uterine cavity
Both tubal ostia visible
IIa Occlusion of the cavity.
Occluding adhesions only in the region of the
internal cervical os
Upper uterine cavity normal
III Multiple dense adhesions Adhesions connecting separate areas of the uterine
cavity
Unilateral obliteration of ostial areas of the tubes
IV Extensive dense adhesions Total/partial occlusion of the uterine cavity
Both tubal ostial areas (partially) occluded
Va Extensive endometrial scarring and fibrosis in combination with grade I or grade II adhesions
With amenorrhea or pronounced hypomenorrhea
Vb Extensive endometrial scarring and fibrosis in combination with grade III or grade IV adhesions
With amenorrhea
8.2.5.2 Clinical Manifestations of Intrauterine after delivery or underwent curettage following incomplete
Adhesions abortions. Diagnostic hysteroscopy was performed 3 months
1. Abnormal menstruation: Intrauterine adhesions usually later. Intrauterine adhesions were found in 20 cases (40%),
lead to menstrual abnormalities, such as hypomenorrhea, with five patients in grade I, six in grade II, six in grade III,
or even amenorrhea, depending on the degree of uterine and three in grade IV. The risk of intrauterine adhesions
occlusion. Patients who have intrauterine adhesions for a grade II–IV in women with menstrual disorders doubled.
long time may also have dysmenorrhea. More than 75% Based on these findings, hysteroscopy is recommended only
of patients with moderate or severe adhesions suffer from in those patients who develop menstrual disorders or repeated
amenorrhea or hypomenorrhea. When uterine atresia is intrauterine manipulations. If the patients have normal ovu-
secondary to intrauterine adhesions, 37% may develop lation but absence of menstruation, then intrauterine adhe-
amenorrhea and 31% hypomenorrhea. Patients with small sion is highly possible. As intrauterine adhesions and
or local adhesion may have no obvious abnormal men- hormone levels are independent, if basal body temperature
struation, presenting with normal menstruation. March shows biphasic pattern and progestogen withdrawal in
et al. reported 275 cases of intrauterine adhesions, men- patients with amenorrhea is negative, the diagnosis of intra-
strual patterns of whom are given in Table 8.15. The inci- uterine adhesions can be strengthened. The determination of
dence of IUA is unknown, and some patients with IUA the ovulation in such patients includes evaluation of basal
are asymptomatic and able to breed normally. body temperature and consecutive serum progesterone lev-
2. Abnormal pregnancy: If the adhesion does not block the els. When the patient has ovulation, the basal temperature
whole uterine cavity, patients may have fertility problems should be biphasic but may be atypical. Since the first day of
and are prone to have pregnancy failures, including mis- an ovulatory cycle is unknown, the early follicular tempera-
carriage in early and mid-term pregnancy, delayed mis- ture may not be detected. Endometrial biopsy is done by tak-
carriage, ectopic pregnancy, premature labor, and ing a sample of fibrous tissues, and progesterone level is
intra-uterine fetus death. In case of a full-term pregnancy, measured once a week until it exceeds 3 ng/mL. If there is
there may be placenta previa, adherent placenta, and pla- ovulatory cycle but without withdrawal bleeding and if no
centa accreta. Schenker and Margalioth evaluated 292 bleeding occurs after administration of progestogen or
patients who had untreated intrauterine adhesions. Of 292 sequential application of estrogen and progesterone, the
patients, 133 (45%) became pregnant, only 50 (30%) existence of IUA should be suspected. The measurement of
obtained full-term pregnancy, 38 (23%) had premature the length of uterine cavity can determine whether there is
labor, 66 (40%) had spontaneous abortion, and 21 (13%) obstruction of the internal cervical os, but this practice had
had ectopic pregnancy and abnormal placenta been discarded, because it can increase the probability of
implantation. uterine perforation and misdiagnosis. HSG had ever been the
3. Infertility: Complete amenorrhea or complete uterine most meaningful examination in the diagnosis of intrauterine
occlusion in patients usually manifests as infertility. adhesions and could be used to evaluate the internal cervical
os and uterine cavity, and describe intrauterine adhesions. If
8.2.5.3 Diagnosis of Intrauterine Adhesions the adhesion does not completely occlude the uterine cavity,
Before the advent of hysteroscopy, the diagnosis of IUA the morphology of the rest of the uterine cavity is shown. If
depended on the case history, physical examination, labora- HSG displays single or multiple filling defects, the diagnosis
tory data, and HSG. The patients with hypomenorrhea or of IUA is more reliable. Intrauterine adhesions have been
amenorrhea after curettage may be suspected to have IUA, confirmed by HSG in about 1.5% of patients with infertility
and the uterus is more likely to be damaged in patients who and 5% of patients with recurrent pregnancy loss. 36% of
are pregnant or shortly after pregnancy than those with a patients with intrauterine adhesions related history are diag-
non-gravid uterus. The occurrence of IUA is more likely in nosed to have IUA by HSG. These adhesions are star-shaped
women who had curettage 2–4 weeks after delivery or and irregularly star-shaped with strips and dots inside and a
delayed miscarriage. Westendorp et al. prospectively studied rough outside, located in different parts of the uterine cavity.
50 women who had their residual placenta removed 24 h Adhesions are usually located in the central part of uterine
cavity, with only a few located in the uterine cornua or lower
segment of uterus.
Table 8.15 Menstruation in 275 cases with intrauterine adhesions
Menstrual patterns Case load 8.2.5.4 Role of Hysteroscopy in Diagnosis
Amenorrhea 183 of Intrauterine Adhesions
Hypomenorrhea 50 HSG is an effective diagnostic method for suspected IUA,
Oligomenorrhea 5 which can determine the degree of uterine cavity occlu-
Normal menstruation 37 sion, but it cannot assess the toughness and type of adhe-
sions. Therefore, the final diagnosis can only be determined there is not enough experience to prove that these tech-
by direct hysteroscopic examination, and diagnostic hys- niques can be the substitutes for HSG, and they are expen-
teroscopy is the final arbiter in the diagnosis (Fig. 8.84a–d). sive as well.
Hysteroscopy can rule out 30% of the abnormal results on March reported that HSG and hysteroscopy have a good
HSG under direct vision, and is superior to HSG in the correlation in the diagnosis of IUA (Table 8.16). HSG often
determination of the extent and the type of adhesions. exaggerates the extent of adhesions. There were two most
Once the final diagnosis is made by hysteroscopy, the cor- dramatic cases who had endometrial sclerosis but no intra-
responding treatment can be administered. Other tech- uterine adhesions, in whom complete uterine atresia was
niques, such as ultrasonography and MRI, have been used diagnosed by HSG. No cases have severe IUA diagnosed by
in the diagnosis of IUA, but their accuracy is not clear, and HSG as it is by hysteroscopy.
a b
c d
Fig. 8.84 Intrauterine adhesions. (a) filmy. (b) fibromuscular. (c) connective tissue. (d) connective tissue
Table 8.16 Severity of IUA diagnosed by HSG and hysteroscopy Table 8.18 Various endometrial histopathology and incidence of uter-
ine bleeding in 1295 cases with D&C
Hysteroscopy
HSG Case load Severe Moderate Mild Incidence of uterine
Severe 124 81 35 8 Endometrial histopathology bleeding(%)
Moderate 37 0 29 8 Functional or non-synchronous 66.6
Mild 43 0 0 43 endometrium
Total 204 81 64 59 Atrophic endometrium 72.5
Adenomatous hyperplasia 77.4
Endometrial polyps 78.1
Table 8.17 Relationship between IUA diagnosed by hysteroscopy and Glandular endometrial hyperplasia 79.3
menstruation Endometrial carcinoma 97.2
Cystic endometrial hyperplasia 100
Extent of intrauterine
adhesions
Menstruation Case load Severe Moderate Mild
Amenorrhea 183 110 49 24 The incidence of bleeding caused by cystic glandular
Hypomenorrhea 50 10 24 16 endometrial hyperplasia and endometrial carcinoma is
Oligomenorrhea 5 1 1 3 extremely high, and the prodromal symptom of other lesions
Normal menstruation 37 4 8 25
is also hemorrhage. Therefore, hysteroscopy can be consid-
Total 275 125 82 68
ered as a reasonable inspection technique in examining
women ≥45 years old with AUB. Biopsy under direct vision
Relationship between hysteroscopic diagnosis of IUA and is especially useful in discovering endometrial carcinoma
menstrual patterns reported by March is given in Table 8.17. earlier and may also make correct diagnosis for benign
Most amenorrhea patients suffer from severe or moderate lesions causing bleeding.
intrauterine adhesions. However, March et al. reported that
nine patients with moderate intrauterine adhesions and 5 8.2.6.1 Diagnostic Methods of Endometrial
with severe adhesions had normal menstruation or just Carcinoma
hypomenorrhea. There has always been a lack of simple and accurate methods
Even if intrauterine adhesions are so severe as to induce with minimal invasiveness in the screening and early diagno-
amenorrhea, the endometrium with biological activity can sis of endometrial carcinoma. In addition to the traditional and
still have the potential to develop into cancer. Sandridge the most commonly used D&C and fractional curettage, there
et al. reported that a 71-year-old woman who developed are a few reports in the literature on the application of other
post-menopausal bleeding with the use of unopposed estro- alternative techniques for detection of the endometrial neo-
gen. At TVS a polypoid mass was detected. Extensive intra- plasm and pre-cancerous conditions including endometrial
uterine adhesions were noted during hysteroscopy, and a cytological examination, HSG, TVS, SHSG (SIS), MRI, diag-
polypoid lesion was seen around the adhesion, with biopsy nostic hysteroscopy, and endometrial biopsy, etc. Blind D&C
confirming endometrial adenocarcinoma. is often inaccurate, and the small cancer foci may be missed at
curettage, which may be located in the deep uterine cornua or
behind submucosal myomas. Gimpelson et al. reported that
8.2.6 Endometrial Carcinoma 10–35% of the endometrial area could not be scrapped. For the
elderly women with the cervix atrophy, the procedure can only
Endometrial carcinoma is a common malignant tumor of the be completed after uterine dilatation, which increases trauma
female genital tract, and its incidence has been slightly on to the patients and their pain. Blind diagnostic curettage can-
the rise in recent years, and the age of onset has a tendency not assess the location and the extent of endometrial cancer.
to be delayed. Direct biopsy under hysteroscopy and patho- Endometrial cytology smears may provide false negative
logical examination are the optimal methods in screening results, especially in well-differentiated or small tumors. HSG
high-risk populations for early detection and accurate diag- may suggest endometrial carcinoma, but usually misleading.
nosis of endometrial carcinoma and precancerous lesions. Krample et al. studied the diagnostic accuracy of TVS, SHSG,
In more than 90% of patients with endometrial carci- operative hysteroscopy, and the histological diagnosis. The
noma, the first symptom is AUB, and the initial symptom of results showed that the detection rate of intrauterine pathology
most benign and malignant endometrial lesions is also bleed- with hysteroscopy and histological biopsy was 100%, and it
ing. Zampi et al. made an analysis of the incidence of uterine was 94.1% with SHSG, but 23.5% with TVS. The endometrial
hemorrhage under various morphological changes of endo- lesions detected by TVS and SHSG still also required direct
metrial tissues in a group of 1295 patients who underwent biopsy through a hysteroscope. Modern hysteroscopic tech-
D&C, which is given in Table 8.18. nique makes a gynecologist able to observe the whole uterine
cavity directly and closely without blind zones. Its small diam- ally performed due to AUB. Therefore, during inspection the
eter and multi-purpose design can prompt the implementation hysteroscopist must pay close attention to various aspects of
of directed biopsy of endometrium, especially the advent of the endometrial tissues including color, undulation and
fiber hysteroscopy, which can be applied for the diagnosis of toughness from the surrounding normal endometrium.
intrauterine diseases in elderly women. Hysteroscopy, being a Neoplasm is highly suspected when there are atypical blood
simple operation providing accurate diagnosis, has become a vessels. The findings on endometrial carcinoma at hysteros-
“gold standard” of modern diagnosis of intrauterine lesions. A copy are very distinct and rarely confused with that of other
great deal of data in recent decades showed that hysteroscopy lesions. The endometrial carcinoma at early stage presents
has been applied in screening of intrauterine lesions for a large an image of one beginning to overgrow, and the endome-
number of outpatients and early detection of endometrial can- trium is irregular and appears to be foliose. The protruding
cer with satisfactory results, which has been accepted by the part is fragile and usually necrotic in nature, which bleeds
majority of women. Currently, hysteroscopy can provide the easily. New vessels are irregular and spiral (Figs. 8.85a,b and
most reliable information on the diagnosis of endometrial can- 8.86a–c). In some cases, the boundary between neoplasm
cer and the extent of intrauterine invasion. In most cases, hys- and the normal endometrium is quite clear. Sometimes focal
teroscopy can clearly observe tumors and predict the prognosis. lesions are visible and located in the uterine cornua, which
Hysteroscopy can reveal the extent of tumor extending out- are easily missed in blind sampling. Endometrial cancer can
ward more obviously than HSG, but it cannot detect the depth be classified into the focal type and the diffuse type accord-
of myometrial invasion. It should be noted that visual inspec- ing to the morphology and extent of the lesions. According to
tion cannot replace pathological diagnosis, thus sampling the orientation of growth, they can be classified into endog-
must be taken for histopathological examination. enous and exogenous lesions. The exogenous lesions often
develop into the uterine cavity with a higher incidence and
8.2.6.2 Hysteroscopic Diagnosis of Endometrial special appearance, which can be diagnosed under hysteros-
Carcinoma copy. However the diagnosis of the endogenous lesions is
Due to technical and anatomical reasons, endometrial cancer more difficult. The basic findings at hysteroscopy include
at an early stage does not present nodular structure which is papillary, nodular, and polypoid swellings, which can appear
detectable by screening. The diagnostic hysteroscopy is usu- separately, and in mixed forms as well. When the lesions
a b
Fig. 8.85 Endometrial carcinoma. This 36-year-old patient has had endometrium with leafy swelling and protrusions, which were greyish
amenorrhea for 10 years after curettage due to incomplete abortion. Her white in color and bleeds easily. Endometrial adenocarcinoma (medium
menses resumed when she received cyclic hormone therapy or proges- to high differentiation) was confirmed histopathologically. (a) far view
terone. Four years ago, adenomatous endometrial hyperplasia was diag- (b) close view
nosed histopathologically. At that stage, hysteroscopy revealed irregular
a b
Fig. 8.86 Endometrial carcinoma. This 63-year-old patient has had sels are disordered and distributed, being fragile, and bleeds easily. (a)
menopause for 17 years. Intrauterine space-occupying lesions were Nodular swellings on the anterior wall. (b) Cauliflower-like swellings
identified by ultrasonography. Hysteroscopy reveals cauliflower-like on the anterior wall (far view). (c) Cauliflower-like swellings on the
swellings on the anterior and posterior walls, over which the blood ves- posterior wall (close view)
develop, the cancer foci may spread from the focal type into 8.2.6.3 Staging for Endometrial Carcinoma at
a diffuse type, and extensive necrosis, inflammation, and Hysteroscopy
ulcers may also occur. Hysteroscopy may be performed to Liukko et al. investigated with fractional curettage prior to
measure the extent of the endometrial carcinoma involve- hysteroscopy and the specimens of the removed uterus diag-
ment in the uterine cavity so as to determine its focal mani- nosed to be endometrial carcinoma stage I, 16% of which
festation and images, and is also the only method to guide were found to spread into the cervix postoperatively.
targeted biopsy. Stelmachow reported that in 22 cases with stage I endometrial
carcinoma diagnosed by HSG and D&C, nine cases were cer is a commonly used method clinically to prevent its
proved to have stage II by hysteroscopy; and in nine cases recurrence. TMX has weak estrogen-like effects, thus the
with stage II by HSG and D&C, two cases actually had stage treatment may cause specific and hyperplastic endome-
I. These data confirmed the superiority of hysteroscopy in trial lesions, including simple hyperplasia and atypical
defining whether it had the cervical spread or not. When hys- hyperplasia, hyperplasia accompanied with polyp forma-
teroscopy is performed, the cervical canal is checked and tis- tion, polypoid carcinoma, and adenocarcinoma, etc. After
sues are scraped before cervical dilation, thus misdiagnosis a study on 15 authors’ research data, Seoud et al. found
can be avoided. When the cancer tissues invading the cervix that the incidence of endometrial carcinoma in patients
have continuous relations with the intrauterine cancer foci, it taking TMX was 0–8.8%. The endometrial changes in
can be determined to be infiltrating carcinoma, which is patients taking TMX were associated with their
stage II endometrial carcinoma. Single lesions within the endometrial status before medication. Baldini et al. evalu-
cervical canal are more difficult to determine. In addition, ated patients treated with tamoxifen after surgery of
there are endometrial carcinoma tissues often hanging from breast cancer for 6–12 months. After 3–4 years of treat-
the uterine cavity into the cervical canal. Since such lesions ment, they observed a higher incidence of atypical endo-
are not true cervical spreading, differentiation between them metrial hyperplasia and endometrial polyp lesions in the
must be made. The false negative rate of hysteroscopic diag- group of symptomatic patients or patients with endome-
nosis of cervical spread is reported to be 7.9%. Toki et al. trial lesions than among the non-treated group and the
conducted a comparison study of endometrial carcinoma for patients with no endometrial lesions. It has been reported
cervical involvement by hysteroscopy, MRI, and endocervi- consistently that the administration of TMX after breast
cal curettage. It was believed that in diagnosis of cervical cancer operation could induce endometrial carcinoma.
involvement, MRI was focused on detecting stromal inva- Cohen et al. reported that the incidence of endometrial
sion, but hysteroscopy was superior for identifying mucosal carcinoma in these patients was 1.7–7 times of that in
involvement, both of which are complementary to each other general postmenopausal women. Therefore, when the
in evaluating cervical invasion. TVS showed endometrial thickness ≥8 mm, hysteros-
copy and targeted biopsy should be performed.
8.2.6.4 Screening for High-Risk Population
with Endometrial Cancer by Hysteroscopy A large number of studies on the assessment of endome-
Endometrial cancer is closely associated with many high- trial changes in women treated with HRT have proved the
risk factors such as postmenopausal uterine bleeding, espe- safety of HRT, but epidemiological studies have shown that
cially in patients with hypertension, diabetes, obesity, long-term or un-opposed HRT may increase the risk of endo-
high-fat diet, and infertility, and women with hormone metrial cancer. The incidence of endometrial cancer in
replacement therapy (HRT) or taking tamoxifen (TMX) after women receiving exogenous estrogen therapy increases by
breast cancer operation, and women suffering from estrogen 6–12 times. With an increase in the dosage of estrogen and
secreting tumor, etc. Screening for high-risk groups is the prolonged administration time, the risk increases gradually.
focus for prevention and treatment of endometrial cancer. The changes in endometrial hyperplasia during the adminis-
tration of HRT may be focal, thus hysteroscopy with directed
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Operative Hysteroscopy
9
Enlan Xia, Ning Ma, Xuebing Peng, Dan Yu, and Jie Zheng
9.1 An Overview of Hysteroscopic addition, there should be at least three sockets on the wall
Electroresection Surgery which can meet the demand of electricity for operation.
Enlan Xia 9.1.1.2 Gynecologic Operating Table: It Should

Have the Following Functions
Since the early 1970s, hysteroscopic operation has been 1. The patient’s position can be changed quickly to meet the
introduced in clinical practice. At the very beginning, it was requirements of operation.
only used for tubal sterilization, which was achieved by 2. There should be enough space in the operating site so as
electrothermal damage to the interstitial portion of the fal- to facilitate electroresection surgery smoothly.
lopian tube under direct vision of hysteroscope. Due to its 3. There should be a complete distension fluid pump and
low efficacy and higher risk, it was replaced gradually by collecting system so as to adapt to the needs of a large
other methods of treatment. Thereafter, along with the volume of fluid for electroresection surgery.
innovation of technology and constant improvement on 4. It should be able to support a wide range of gynecological
operative instruments and energy source, the hysteroscopic operation in order that the operation can be immediately
operation has also been constantly improved in its safety changed to laparotomy in case of complications.
and efficacy. At present, this minimally invasive approach
of hysteroscopy is gradually replacing the traditional trau- 9.1.1.3 Positioning
matic hysterectomy via laparotomy to treat various intra- The modified lithotomy position is adopted, that is, supporting
uterine and cervical diseases. Due to its minimal the legs with the relaxed knees, placing the thigh at an angle of
invasiveness and high efficacy, it is recognized as the model 45° to the horizontal line, abducting legs as much as possible to
of minimally invasive operations. increase the available space. Compared with full lithotomy
position, this position is advantageous as it is associated with
low intra-abdominal pressure, and so does not interference with
9.1.1 Facilities of Operating Room breathing and providing easy access to the tubal ostia. If lapa-
and Patient’s Body Position roscopy is performed at the same time, bend the thigh at 30°
angle to the horizontal line so as not to affect the laparoscopic
9.1.1.1 Operating Room procedures. Generally, a slightly low head position is adopted.
An operating room should be spacious, with the operating
table put in its center, at the head end of which can be placed 9.1.1.4 Prevention of Infection
the anesthesia machine and monitors used by the anesthetists Prophylactic antibiotics given prior to operation are helpful.
(Figs. 9.1a, b and 9.2a, b). On one side of the patient, there is Intravenous antibiotics can be given once when operation
a multi-layer cart or a medical crane tower with devices on it starts.
including monitor, electricity generator, lighting system,
video camera, fluid distending pump, and other equipment.
An ultrasound machine is always placed on the other side. In 9.1.2 Irrigating Methods in Hysteroscopic
Operation
E. Xia (*) · N. Ma · X. Peng · D. Yu · J. Zheng There are two kinds of pressure in uterine cavity during oper-
ations. One is hydrodynamic pressure, which is generated
Beijing, China

184 E. Xia et al.
a b
Fig. 9.1 (a, b) Full view of hysteroscopic operating room
a b
Fig. 9.2 (a, b) Layout of an operating room
when irrigation fluid is injected in through the endoscope septum or intrauterine adhesions narrow the cavity, the flow
sheath, and determined by the height of irrigation fluid and of irrigation fluid into the uterine cavity would be reduced. In
the hydrostatic pressure of the uterus itself. The other is the cases of obscure vision, the inflow pressure could be
hydrostatic pressure, which is intrauterine pressure, and increased, but should only be temporary.
overcome by consuming hydrodynamic pressure.
9.1.2.2 Low-Pressure Irrigating
9.1.2.1 High-Pressure Irrigating The device containing irrigation fluid is placed at a height of
High-pressure irrigating can help to gain clear vision for 40–60 cm above pubic symphysis. According to the research
easier operation, but there might be an increased absorption on the intravesical electroresection, if an aspiration device
of the irrigation fluid, hemodilution, and reduced blood suctioning irrigation fluid out is used, it indicates that the
sodium. Once uterine perforation occurs, the irrigation fluid pressure within the bladder is almost equal to intravenous
may pass quickly through a perforation into the peritoneal pressure, thus the volume of fluid that enters into the body
cavity. One study on bladder irrigation showed that when the via the cutting surface will decrease greatly. But if there is no
distance between the height of irrigation fluid and the continuous aspiration, the intravesical pressure is up to
patient’s pubic symphysis was 120 cm, the intravesical pres- 30–60 cmH2O (2.94–5.88 kPa); if the height of the device is
sures might be up to 100 cmH2O (9.8 kPa); when the dis- less than 30 cm and there is no aspiration device, the intra-
tance was 80 cm, the intravesical pressure could reach vesical pressure is up to 30 cmH2O (2.94 kPa); if there is a
80 cmH2O (7.85 kPa) (1 cmH2O = 98.1 Pa = 0.736 mmHg). continuous suction, the intravesical pressure may be lower
If an automatic uterine distending pump is applied, the pres- than 30 cmH2O (2.94 kPa), often at 10 cmH2O (0.98 kPa).
sure can be adjusted to the level of mean arterial blood pres- Studies on intravesical electroresection suggested that
sure. When operation starts, if thickening endometrium or irrigation pressure should be maintained at a level of less
large submucous myomas occupy the uterine cavity, uterine than 60 cmH2O (5.88 kPa), which made it relatively safe.
9 Operative Hysteroscopy 185
9.1.2.3 Selection of Irrigation Fluid than the diameter of the resectoscope before hysteroscopic
Irrigation fluid has distending, irrigating, and cooling effects. operations. Difficult dilatation often occurs during operative
The types of irrigation fluid, the intraoperative irrigation hysteroscopy in cervix without ripening. Inadequate cervical
pressure and flow rate, and the operation time are all factors dilatation may lead to cervical laceration, hemorrhage,
affecting the safety of operations. An isotonic nonelectrolyte increased difficulties in operation, prolonged operating time,
solution is required for hysteroscopic monopolar electrore- and increases the risk of uterine perforation and creating a
section so that the electric current generated when cutting or false passage, with a correspondent increase of TURP syn-
coagulating may be focused on the contact part of electrode. drome. If the cervix is ripened and adequately softened
During operations, the irrigation fluid can be absorbed into before hysteroscopic operation cervical dilatation to a diam-
the circulation via open veins of the resection surface or into eter larger than that of the outer sheath of the hysteroscope
peritoneal cavity via fallopian tubes. Since nonelectrolyte could be easily achieved, which could significantly lessen
solution is not physiologic fluid, if a great deal of irrigation the risk of cervical laceration or uterine perforation, decrease
fluid enters the blood circulation, an increase in blood vol- the absorption of distention fluid during operations, and limit
ume and a change in electrolyte composition would result, the occurrence of TURP syndrome.
which may cause systemic pathophysiological changes and a So far, commonly used methods for cervical ripening in
variety of clinical conditions, such as acute left heart failure, clinic include osmotic dilators, misoprostol, and
pulmonary edema, water intoxication, and hyponatremia. phloroglucinol.
The typical symptoms are dysphoria, nausea and vomiting,
slow response, oliguria and kidney failure, etc. In 1955, 9.1.3.1 Osmotic Dilators
Hagstrom named it syndromes of the transurethral resection Osmotic dilators are used for mechanical pretreatment of
of the prostate (TURPS). When selecting irrigation fluid, one cervix, including laminaria tent, silicone rod, and so on,
should take its viscosity, transparency, osmotic pressure, pH, which are generally inserted into the cervical canal at night
half-life, internal metabolism, and end products into consid- before the surgical procedures. With a combination of
eration, and also set a reasonable irrigation pressure. The mechanical stimulation, together with the dilator expanding
commonly used solutions are 1.5% glycine, 5% mannitol, after absorption of water, the cervix is softened and cervical
3% sorbitol, 5% glucose and Cytol solution, etc. canal is dilated (Fig. 9.3a, b). This method is effective and
has been commonly used in clinic.
9.1.3 Cervical Ripening Before Operative 9.1.3.2 Misoprostol

Hysteroscopy Misoprostol is a synthetic prostaglandin E1 analog, which
promotes both the degradation of the collagenous fibers in
Generally, the cervical canal can accommodate an instru- cervical connective tissues and the release of collagenase
ment of up to 3–5 mm, but the outer sheath of a resectoscope and elastase, so that it can soften, ripen, and expand the cer-
is 8–9 mm in diameter, so the cervix should be dilated more vix in a short period of time. Usually, it is taken orally or is
a b
Fig. 9.3 Osmotic dilators. (a) Laminaria tent (the one below is of the original size, and the above is of an expanded size after absorption of water).
(b) Silicone rod (the one below is of the original size, and the above is of an expanded size after absorption of water)
186 E. Xia et al.
inserted into posterior fornix of the vagina at night or 4 h ulation. The inlet flow tubing must be removed before
prior to the operation with a recommended dose of 200– inserting operative instrument. When camera system is used,
400 μg. This method is applicable for cases with difficult the adapter connecting to the camera system should be
insertion of osmotic dilators. assembled to the eyepiece of telescope, and the camera focal
length, white balance, and focus should be adjusted before
9.1.3.3 Phloroglucinol the insertion of the hysteroscope. The correct orientation of
Phloroglucinol is a pro-muscle non-atropine non papaverine hysteroscope during insertion is that the fiberoptic cable
class pure smooth muscle antispasmodic agent, which acts faces downwards and fore-oblique view faces upwards. After
on smooth muscles of gastrointestinal and genitourinary the adapter is connected to the telescope, they should always
tracts. Some research indicated that phloroglucinol was maintain a certain direction and cannot be rotated, instead
superior to lidocaine and misoprostol in both the analgesic the hysteroscope should be rotated clockwise or anticlock-
effect during hysteroscopic diagnosis and the degree of cer- wise to observe the lateral wall of uterine cavity. In addition,
vical distensibility and softness, with side effects less than when using low viscosity distending medium, keep in mind
that of lidocaine and misoprostol. As one of the methods that a plastic collection bag is placed under the patient’s hips
applied for ripening and softening the cervix prior to hys- to collect the intraoperative outflow of liquid, thus the fluid
teroscopic operation, phloroglucinol injection is especially deficit can be accurately measured and the floor will not
useful in long hysteroscopic resections and cases with medi- become wet.
cal complications such as hypertension and glaucoma, etc. It Before placing the endoscopic sheath with its telescope,
is applied by intravenous drip 15–30 min prior to operation manipulator handpiece, and active electrode into uterine cav-
at a dose of 40–80 mg, which should be finished in 5 min. ity, be sure to open the inlet and outlet valve, and empty the
The duration of action is around 45 min. gas out of inflow tubing. When operation begins, switch on
continuous flow system, and then irrigate and flush intrauter-
ine tissue fragments and blood clots. Sometimes, if there is a
9.1.4 Techniques of Hysteroscopic larger blood clot blocking the sheath and hindering the circu-
Electroresection lation of irrigation fluid, the hand piece and telescope and the
inner sheath must be taken out and cleaned. After achieving
9.1.4.1 Operating Procedures a clear vision of the uterine cavity and connecting to the elec-
The patient is put in lithotomy position on the operating tric cables, the operation can be started. Monopolar circuit is
table, then the external genitalia is routinely sterilized. If cer- usually used for hysteroscopic resection. Before switching
vical dilator had been inserted, the assistant should wear on the power for operation, remember to check the return
sterile gloves and remove it from the vagina, which can avoid electrode attached to the patient to ensure a complete current
the likelihood of fracture of cervical dilator caused by other circuit. In this condition, nonelectrolyte solution must be
methods or partial retention in the uterine cavity. Then used as distention medium, some active electrodes should be
sterilize the vagina and cervix, place vaginal speculum and prepared for spare use so that an active electrode can be
hold anterior lip of the cervix with a cervical clamp, dilate replaced in time when tissue fragments adhere to the elec-
the cervical internal os gradually until an operative hystero- trode making it no longer effective. The replaced electrode
scope can be introduced, which is usually 9–10 mm. Next, can be reused after being cleaned.
connect the telescope to light sources, distention tubing,
electricity generator and electric cables, and working ele- 9.1.4.2 Techniques of Resecting
ment. The obturator should be inserted with the sheath into 1. Anterograde resection: First push the wire loop out of
the cervical canal so that its tip may further dilate cervical sheath and extend to a distant position (Fig. 9.4a), then do
internal os. After entering the uterine cavity, the obturator parallel cutting from distal to proximal according to the
should be taken out, and then telescope and its handpiece requirements on the depth and length of resection
should be placed into operative sheath for operation. When (Fig. 9.4b, c). It is one of the most commonly used tech-
the low viscosity distending medium is used, the handpiece niques, easy to master and convenient to use. One can see
should be connected to two polyethylene tubings with clearly under hysteroscope the moving process of the
2.4 mm of outer diameter and 1.6 mm of inner diameter. electric wire loop from the distal to the proximal part,
Under certain pressure, fluid flows in and out of uterine cav- which means one would not cut other tissues in error, so
ity via inflow and outflow channel, thus forming a continu- it is safe. When the sheath is pulled back, longer strips of
ous cycle, which can remove the mucus, tissue fragments, tissues can be cut out by anterograde resection (Fig. 9.4d).
and blood clots in uterine cavity so as to maintain a clear 2. Retrograde resection
vision in operational field. For discontinuous flow hystero- This method is opposite to the above. Place the electric
scope, it has only one channel for both inlet flow and manip- wire loop at proximal site of the tissues to be removed
a b
c d
Fig. 9.4 Anterograde resection. (a) First push the wire loop out of proximal. (c) According to the requirements on the cutting depth and
sheath and extend to the distant position. (b) According to the require- length, do parallel cutting from distal to proximal. (d) The excised long
ments on the cutting depth and length, do parallel cutting from distal to strips of tissues with wire loop
and then extend it to the distal site gradually while cut- (a) There are more tissues to be excised, and one cannot
ting, and cut it off when the electric wire loop reaches the see clearly the boundary of distal end.
edge of tissues to be resected. Retrograde resection is not (b) When the lower border of tissue to be excised is float-
easy. Doctors cannot see the distance clearly when elec- ing and is difficult to resect anterogradely.
tric wire loop moves towards distal end, and carries a (c) If some residual tissues are still connected to the sur-
higher risk of pushing the wire loop into the uterine wall, face and floating, resecting anterogradely would be
even causing perforation. This method is applicable to the more difficult and retrograde resection should be
following situations. applied.
188 E. Xia et al.
3. Vertical resection: It is cutting by electric wire loop from thin slice is lighter than a thick slice. (2) current selection:
top to bottom. If vertical cutting method is adopted, excised tissue is lighter with blended current than that with
movement of the wire loop can be achieved by moving single cutting. (3) coagulation method: The loss in weight
the endoscopic sheath up and down appropriately. This by aimless excessive electrocoagulation is limited, and the
method is suitable for resection of large fibroids. excised tissue will be lighter with target electrocoagulation
4. Transverse resection: The wire loop makes a transverse hemostasis.
resection by moving from left to right or from right to
left. The wire loop can be moved sideways by moving the 9.1.4.5 Volume Assessment of Bleeding
endoscopic sheath transversely. This method is suitable in Hysteroscopic Resection
for the removal of the tissues at the uterine fundus and the The intraoperative bleeding quantity mainly depends on the
uterine septum. extent of bleeding on cutting surface and duration of resec-
tion. The related factors are as follows:
9.1.4.3 Electrocoagulation Hemostasis
1. Resection methods: One cutting followed by one coagu-
1. The electric wire loop can coagulate directly at spraying
lation has less bleeding, but a longer operation time; sev-
bleeding point. If ineffective, it may be due to a large arte-
eral cuttings followed by one coagulation have short
rial bleeder or the mis-match of the direction of the
operative time, but slightly more blood loss.
bleeder and the electrocoagulation application site.
2. Operator’s proficiency: A skilled operator may be fast
Therefore the electrode should be moved to coagulate at
both in resection and hemostasis, leading to the reduction
the adjacent sites of the bleeding point.
of bleeding.
2. Rollerball electrode can be used to coagulate and achieve
3. Resected tissue volume and resection time: The more tis-
hemostasis. On coagulating surface of tissue, it forms
sue volume excised and the longer resection time it takes,
flake eschar and results in tissue necrosis and shedding
the more bleeding it will have.
after operation, which may cause secondary hemorrhage.
4. Types of current applied: Blended current produces less
3. If there are large blood vessels on the surface of tissue to
bleeding.
be excised, vascular electrocoagulation should be done
5. If the cutting depth reaches 5–6 mm, which might involve
before cutting the tissue.
deeper and larger vessels, more bleeding would occur.
6. Pathological changes in the uterine muscles: The patients
9.1.4.4 Weight Calculation of the Excised Tissue
with fibrosis of uterine myometrium will have less bleed-
The electric resected tissue is light-weighted, which has two
ing. On the other hand, patients who have chronic inflam-
reasons.
matory in uterus will have vascular proliferation,
1. When a complete tissue is cut into a dozen or dozens of increased blood supply, and poor uterine muscle contrac-
slices, the blood, lymph and tissue fluid within the tissue tion, leading to more bleeding.
may exude and be lost from its surface.
2. The burning effect caused by coagulating and cutting on 9.1.4.6 Calculation Method of Blood Loss
tissue cells can cause dehydration of tissue and cell atro- It is more accurate to measure the hemoglobin concentration
phy, which may further reduce the weight of tissues. in outflow irrigation fluid. Usually it is direct colorimetry
According to reports on transurethral resection of pros- with test tubes, or colorimetry with photoelectric colorime-
tate, different authors reported the reduction of tissue ter. The minimum depth value of general colorimeter is 40%,
weight differently. It was 20% less in Einarsson’s report, but the hemoglobin concentrations in outflow irrigation fluid
but about 30% less in Ruter’s report. Yang in China is far below this level, so a special colorimeter is needed for
applied electric cutting on isolated prostate, then weighed colorimetric determination. A commonly used method is:
the tissue, and found that the weight reduced by firstly, measure hemoglobin concentration directly in out-
23–42.8%, the average being 32.6%. flow irrigation fluid (%); then compare the patient’s preexist-
ing hemoglobin concentration, and the blood loss volume
The weight assessment of the excised tissues is also can be obtained. Calculation formula is as follows.
related to the following factors: (1) resection methods: A
Blood loss volume ( mL ) = the total irrigation volume ( mL ) × measured hemoglobin ( g ) × 100 / Original hemoglobin ( g )
In recent years, plasma bipolar resectoscope has been Table 9.1 Cases of hysterectomy in the USA from 1975 to 1995
introduced. Its cutting and coagulating are consistent with Year Number of cases Rate(‰)
those by monopolar resectoscope mentioned above, except 1975 724,000 0.6
that a second cutting on the cut surface will be more difficult 1976 701,000 8.1
due to the increase in local current impedance. Distention 1979 639,000 7.1
1981 674,000 7.3
with normal saline is used when bipolar electric cutting is
1983 673,000 6.9
applied, which will reduce the occurrence of hyponatremia.
1985 670,000 6.7
In 2007, Ho et al. made a prospective comparison study of 1987 653,000 4.6
transurethral resection of the prostate among 52 patients in 1988 578,000 4.3
the monopolar group and 48 in the transcervical resection in 1989 541,000 –
saline (TCRis) group. The results showed that mean resec- 1990 591,000 –
tion time and mean weight of resected tissues were compa- 1991 546,000 –
rable in both groups. The mean postoperative serum Na+ was 1992 580,000 –
reduced, being 3.2 mmol/L in TURis group and 10.7 mmol/L 1993 562,000 –
in monopolar group (p < 0.05). However, there was no statis- 1994 556,000 –
1995 583,000 –
tical difference in the drop of Hb level following operation
between the two groups. It was concluded that it was safer to
use bipolar resection. tries started to carry out this operation. In 1987, De Cherney
from the United States used a prostate resectoscope to stop
the bleeding successfully in a woman who suffered from
9.2 Transcervical Resection intractable uterine bleeding due to hematological diseases,
of Endometrium and Endometrial thus creating a precedent in the treatment of endometrial dis-
Ablation ease by resectoscope. In 1988, Lin from Japan reported on
the electrocoagulation of the endometrium by rollerball elec-
Enlan Xia trode in the treatment of uterine hemorrhage, which achieved
satisfactory results and was named endometrial ablation
Transcervical resection of endometrium (TCRE) is a pro- (EA). Now some scholars called it rollerball endometrial
cedure using high-frequency electricity via hysteroscopic ablation (RBA). In 1989, Magos from the United Kingdom
resectoscope with usually monopolar loop electrode to resect published his preliminary report on hysteroscopic resection
functional and basal layers of endometrium as well as under- of endometrium with loop electrode for treatment of menor-
lying 2–3 mm myometrium. Endometrial ablation is a hys- rhagia in 16 women who had systemic diseases. After a
teroscopic procedure with high-frequency electricity to 6-month follow-up, the effective rate was reported to be
coagulate endometrial tissues using monopolar rollerball, or 86%, and this procedure was named transcervical resection
to vaporize endometrial tissues using vaporizing electrode. of endometrium (TCRE). At present, there have been no uni-
Both operations lead to postoperative non-regeneration of form Chinese translation of TCRE or EA; the commonly
endometrium, and decreased menstruation or amenorrhea, used nouns for it are endometrial resection, and endometrial
thus being the preferred surgical treatment for AUB. Before ablation. Other translations for it include endometrial dele-
the advent of hysteroscopy, hysterectomy was the treatment tion, endometrial dissection, endometrial incision, endome-
for women with intractable uterine bleeding who was irre- trial coagulation, endometrial destruction, etc. Scholars
sponsive to the conservative hormonal treatment and abroad hold that when the endometrium was resected in this
D&C. Some information about cases of hysterectomy in the procedure, the partial superficial myometrium was also
United States from 1975 to 1995 can be seen in Table 9.1. removed, so it should be called endomyometrial resection.
According to data counted by New York State Department of Some scholars performed the procedure of resection to a
Health, 35,000 cases of hysterectomy were performed each depth of 4–5 mm beneath the endometrium, resecting deeper
year, among which 10–15% were due to the abnormal men- in myometrium layer.
struation without obvious organic diseases. Hysterectomy is
a radical measure to eliminate the symptoms, but it is an
open surgery, which requires hospitalization of the patient 9.2.1 Indications and Contraindications
for days and obviously restricts patients’ activities, and the of TCRE or EA
patient may also suffer from complications. Since 1980s,
TCRE and EA have reasonably replaced hysterectomy. The main indications for TCRE are abnormal uterine bleed-
In 1981, Goldrath from the United States first applied ing (AUB). Generally, the anovulatory AUB is called dys-
hysteroscopic endometrial ablation by laser (HEAL; or functional uterine bleeding, referred in brief to as DUB; the
endometrial laser ablation, ELA), and thereafter, many coun- ovulatory AUB is termed menometrorrhagia. The latter can
190 E. Xia et al.
be divided into menorrhagia and metrorrhagia, the former 4. Acute period of heart, liver, or kidney failure.
refers to a heavy bleeding during menstrual period in women 5. The patient has no good psychology bearing capacity for
with ovulation; the latter refers to irregular bleeding in the the fact that this operation is to relieve symptoms rather
ovulatory period. The most common causes for menorrhagia than a radical cure.
are uterine fibroids, endometrial polyps, and adenomyosis.
Moreover, there are some other causes like IUD with no pro- Recently, Neis and Brandner pointed out that patients
gesterone, hypothyroidism, idiopathic menorrhagia, blood with dysmenorrhea plus uterus >10 weeks were highly likely
diseases, and other serious medical diseases such as renal to have adenomyosis. Surgery of TCRE in these patients had
failure, liver failure, leukemia, and drug-induced menorrha- an increased failure rate, therefore it should be considered as
gia. Any factors resulting in a normal estrogen secretion but a relative contraindication of TCRE.
anovulation may lead to endometrial hyperplasia manifest-
ing as DUB, which should be regarded as pathological,
except for physiological bleeding after menarche or within 1 9.2.2 Preoperative Preparations
year of perimenopause. During HEAL in destroying the
endometrium, the endometrial polyps and small aggregated 9.2.2.1 Inquiry of a Detailed History
submucous myomas can also be removed. EA can be used 1. Age: Most patients with dysfunctional uterine bleeding
not only to remove the endometrium, but it can also remove and uterine myoma are over 40 years old, and these
the coexistent endometrial polyps and small fibroids if using patients are selected for TCRE. The younger women
vaporizing electrode. The evolution process of TCRE indica- should receive treatment with sex hormone in advance for
tions can be divided into four stages. Stage 1: In 1987, De three reasons: (1) DUB are often temporary endocrine
cherney used TCRE to treat women who had chronic and disorders, and may recover spontaneously; (2) future fer-
intractable bleeding but were reluctant to remove the uterus, tility problems; (3) high recurrence rate. However, sur-
or women who couldn’t tolerate the removal of uterus due to gery should be considered if a patient has the following
serious medical problems. Stage 2: Because of its positive conditions: having no response or having too serious side
effects on hemostasis, in 1989, Magos extended this opera- effects to drug therapy; having already been sterilized or
tion to the patients who had menorrhagia and who volun- bleeding seriously which has obviously affected family
tarily underwent the operation. A submucous myoma with its life and work; being the only alternative to hysterectomy
size <3 cm can be removed at the time of endometrial sur- in young girls with blood diseases. Surgery in women
gery if the uterus is not bigger than 8 weeks. Stage 3: In close-to-menopause must be prudent, because it may be
1990, Shar reported the application of it for sterilization; possible for them to avoid any surgery. Therefore, all the
Garry reported using it to perform partial resection of endo- perimenopausal women must have examinations of the
metrium for women without AUB, which was intended to LH/FSH and estrogen level to conclude an appropriate
reduce the blood loss physiologically and “normalize” the treatment. When postmenopausal women are treated by
menses. Stage 4: due to the proficient techniques, and hormone replacement therapy, most regular withdrawal
improved equipment, in 1991, Magos proposed its operative bleeding is periodic and with less volume. If the bleeding
indications should be extended to the uterus with size <12 was excessive, hysteroscopic surgery might be consid-
weeks, the length of the cavity <14 cm, and submucous ered, but endometrial atypical hyperplasia or malignant
myoma with no regard to its size and location. Generally, the diseases should be excluded.
operator may grasp the following standards. 2. Parity: At the beginning of surgery, a cervix shall be
dilated at least to Hegar 10 for the placement of the resec-
9.2.1.1 Indications toscope. Most patients who underwent TCRE have
1. Intractable abnormal uterine bleeding, excluding malig- already given birth to children, thus their cervixes are
nant diseases easy to be dilated. For a woman with no parturition, the
2. Uterus ≤9 weeks of gestational size, uterine cavity cervix may be long and hard to be dilated, thus preopera-
≤12 cm in length tive insertion of cervical dilator or application of prosta-
3. Submucous myoma ≤5 cm in diameter glandins shall be done to soften the cervix.
4. No requirements for fertility 3. Adaptability of the operation: TCRE requires shorter
operating time than hysterectomy, and is advantageous to
9.2.1.2 Contraindications those with medical complications. The operation can be
1. Cervical canal could not be dilated adequately because of performed under local anesthesia, but it is still difficult in
cervical scars. the lithotomy position for the patient with severe respira-
2. The hysteroscope cannot reach the uterine fundus due to tory disease. There are the same situations for patients
extreme bending of the uterus. with bronchitis, emphysema, coronary heart disease,
3. Acute stage of reproductive tract infection. hypertension (especially heart enlargement),
insulin-dependent diabetes mellitus, and chronic kidney is almost painless, or produces premenstrual abdominal
disease with impaired renal function. Pathological obe- pain possibly due to the pelvic congestion. Patients with
sity can cause complications of anesthesia and surgery. endometriosis or adenomyosis can have lower abdominal
The ordinary obese women are more suitable for TCRE pain before, during, or after menstruation, often accom-
than hysterectomy, because the complications of the lat- panied by severe low lumbar pain. A careful differential
ter are more serious. The main problems of obese patients diagnosis should be made because TCRE cannot cure
are that the size of the uterus and the pelvic lesions are not these two diseases. After TCRE, the patient may have no
easy to identify, and circulatory complications resulting menstruation, but if severe dysmenorrhea persists, the
from excess absorption of distention fluid must be only management is to remove the uterus.
avoided. Therefore, inflow and outflow volume must be 7. Past history of uterine operation: If the patient had uterine
precisely measured, and even if the difference between operations such as repeated curettage or myomectomy,
the inflow and outflow volume (referred to as fluid deficit) especially opening the cavity or a history of cesarean, it is
is very small, the operator should also be reminded and possible to have intraoperative uterine perforation, so
suspend operation when necessary. close attention should be paid.
4. Fertility: Successful TCRE can lead to amenorrhea and
infertility, which can be accepted by elderly women. But 9.2.2.2 Comprehensive Examinations
to young women, the operator should explain carefully 1. General physical examination: A general physical exami-
and make them understand fully the consequences of nation includes blood pressure, pulse, and a complete
infertility and ectopic pregnancy. In contrast, patients who systemic checkup. If necessary, doctors in relevant
have postoperative cyclical bleeding, regardless of the departments should be invited for consultation.
amounts, have the risk of pregnancy. If the embryo is 2. Gynecologic examination: For a patient with DUB, the
implanted in the residual endometrial island, the preg- uterus is small but movable and the ovaries are not
nancy may continue to full term, but placenta may develop enlarged. If the uterus is retroverted and fixed, or there is
pathological adhesion, even deep implantation, leading to a mass in the adnexa, endometriosis should be suspected.
difficulty in the third stage of labor. Such patients should The posterior fornix tenderness or nodules may be sus-
take proper contraceptive measures. It may be more appro- pected to be uterine rectovaginal septum endometriosis
priate that TCRE is performed along with laparoscopic lesions, and a bulky uterus with tenderness indicates that
sterilization procedures, which can also prevent the irriga- it may be adenomyosis. Adenomyosis can sometimes
tion fluid entering into the peritoneal cavity. proliferate in the local portion of uterus, thus enlarging
5. Bleeding: Prior to operation, to determine whether or not the uterus, which appears to be fibroids under internal
the patient is suitable for operation, the amount of blood examination. If the uterus is irregular in shape, it could
loss is crucial, but is very difficult to measure accurately, be multiple myomas, which were difficult to be treated
because it is usually estimated subjectively and may be with laser or resectoscope. The most suitable operation
different monthly. Generally, if the patient has the follow- of hysteroscopy is submucous myoma, which should be
ing conditions, she is obviously to be diagnosed menor- suspected when the cervix external os tries to open wide
rhagia: there are blood clots or blood gushing, which the to discharge myoma. The pelvic inflammatory disease
perineal pad cannot absorb quickly and needs to be can induce abdominal pain, uterine tenderness, and men-
changed every hour; one may feel tired and short of strual cycle changes, which cannot be cured by
breath, or postmenstrual weakness and fatigue, and low TCRE. One important single index of successful TCRE
hemoglobin with small cell anemia due to blood loss. The is the size of the uterus, especially the length of uterine
periodical menorrhagia may respond well to TCRE, but if cavity. If the size of the uterus is >12 weeks of gestation
the patient has midcycle bleeding, premenstrual or post- or the length of uterine cavity >12 cm, operation would
menstrual bleeding, or spotting, she should be examined be very difficult, operation time would be prolonged, and
carefully so as to exclude endometrial hyperplasia or the risk of cardiac vascular overload would be increased
endometrial polyp. as well.
6. Pain: Massive bleeding is often accompanied by severe 3. Laboratory tests: Laboratory tests include hemoglobin,
cramps caused by passing blood clots from the uterus. white blood cell counts, platelet, bleeding and coagula-
Pain is often confined to lower abdomen, suprapubic and tion time, blood type; urine routine tests; liver and renal
upper thighs, usually bilateral and rarely unilateral, and functions; Australia antigen (HBsAg), anti HCV anti-
the lower lumbar pain is rarely seen. The pain can reach a body; cervical smear test; vaginal thrush, cleanliness and
climax when blood clots pass through the cervical canal. trichomonas inspection under microscope; if necessary,
The cramp cannot be distinguished from the pain caused erythrocyte sedimentation rate, blood glucose, lipids,
by submucous myoma or endometrial polyp. On the con- and sex hormone; thyroid function including T3, T4,
trary, hemorrhage resulting from the endocrine disorders TSH, etc.
192 E. Xia et al.
4. Special examinations: Special examinations include elec- 2.5 mg orally, 2 times/week, for 4–12 weeks; (3) GnRH
trocardiogram, chest X-ray and other internal medical analogs: the currently used GnRH analogs are goserelin
diseases are suspected. 3.6 mg, intradermal deposit; triptorelin 3.75 mg, intra-
5. Ultrasound examinations: Ultrasound examinations help muscular injection; leuprorelin 3.75 mg, subcutaneous
to understand the size, shape, location and echoes of the injection. All of them should be administered once every
uterus, the direction of endometrial line, thickness of 28 days, 1–3 times. Among these agents, GnRH analogs
endometrium, and whether adnexa have mass or not. For are the best but very expensive.
those who take drugs to inhibit endometrial hyperplasia, Donnez et al. reported that after the use of GnRH ana-
transvaginal ultrasonography can be used to estimate logs, both the endometrium and stroma atrophied sharply,
endometrial thickness. An enlarged ovary indicates endo- which was only 1.6 mm in thickness, but 3.4 mm in those
metriosis, or benign/malignant tumors. who didn’t take it. Romer reported that for those who had
6. Hysteroscopy: Hysteroscopy can provide accurate infor- preoperative application of GnRH analogs, the postopera-
mation about the size and shape of the uterus, whether tive amenorrhea rate was 42%, while only 24% for those
there are polyps and submucous myoma, inner bulge and who didn’t use GnRH analogs. Sowter et al. made a ran-
deformation, etc. It can also estimate the possibility and domized comparison of pretreatment effects of danazol,
difficulty of operation, and locate the site for biopsy. progesterone, and GnRH analogs on endometrium in
7. Endometrial biopsy: 25% of the perimenopausal women intraoperative endometrial thickness, operation time,
with moderate and severe atypical hyperplasia of endo- operation difficulty, irrigating fluid absorption rate and
metrium may develop into endometrial adenocarcinoma. incidence of complications, postoperative amenorrhea
Therefore, an endometrial biopsy must be taken so as to rate, menstrual volume, dysmenorrhea, and further treat-
exclude endometrial atypical hyperplasia and endome- ments. The results were that GnRH analogs had a more
trial carcinoma. lasting effect than danazol in endometrial atrophy, while
there was minimal difference in other intraoperative and
9.2.2.3 Consultation postoperative outcomes. Steffensen and Hahn (1999)
Good consultation is the key to make the patients satisfied, studied the effects of TCRE on the incidence of fluid
so the operator should explain in detail the infertility, hemor- overload, factors associated with fluid overload, and rela-
rhage, short-term complications, long-term prognosis, likeli- tionship between the fluid overload and long-term prog-
hood of recurrence, final demand for hysterectomy, and other nosis. The result was that in 265 patients with 1.5%
issues. The operator should also point out that although glycine solution as irrigation fluid, fluid absorption was
abnormal bleeding may be significantly improved post- increased after the application of GnRH-a in patients
operation, a small percentage of women will have or develop treated with TCRE (P < 0.007), and also removal of
cyclical abdominal pains, which may be very troublesome. myoma during the procedure of TCRE (P < 0.0001). Rai
The patients should also be warned that even though there et al. carried a study investigating whether or not the
are reports about the postoperative improvement of primary medical pretreatment of endometrium helped to improve
dysmenorrhea and premenstrual tension syndrome, it has no long-term outcome of TCRE. Three endometrial pretreat-
therapeutic effect on the premenstrual tension syndrome ment agents were used in comparison: danazol, leupro-
because this operation doesn’t affect ovarian function. There lide, and nafarelin. The cases without pretreatment were
should be written explanations to guarantee that the patients included as control group. The measures for determina-
are fully informed about the operation and a formal consent tion of prognosis included thickness of the resected endo-
should be obtained from the patients. metrium and myometrium; stage of the endometrium at
the time of operation; the situation of menstruation and
9.2.2.4 Endometrial Pretreatment patient satisfaction 1 year after surgery. Of the three pre-
The detailed endometrial pretreatment can be seen in Chap. 4. treatment groups studied, compared with control group,
danazol and nafarelin produced significantly endometrial
1. Medical Pretreatment: Medical pretreatment can induce thinner (thin and moderate thickness). Danazol showed
atrophy of the endometrium, decrease the uterine volume, the greatest ability to induce atrophy of the endometrial
and reduce vascular regeneration, thus leading to a short- glands and stroma and produced a high amenorrhea rate
ened operation time, less bleeding, and an easy operation, (no statistical difference). Compared with the control
and it can be done at any time during the menstrual cycle. group, there were no significant differences in amenor-
The reduction of absorption of intraoperative distending rhea rate in any pretreatment group, and if the procedure
fluid improves the safety and efficacy of the operation. was done at the proliferative phase of the menstrual cycle,
The commonly used drugs are: (1) danazol: 200 mg there would be no significant improvement in clinical
orally, 2–4 times/day, for 4–12 weeks; (2) nemestran: outcome for patients in pretreatment groups.
Fig. 9.6 After being inserted into the cervical canal on the night before
operation and followed by removal prior to operation, an osmotic dila-
tor is seen expanded and widened
9.2.2.7 Preparation on Operation Day

On the morning of operation, the patient should have fasted
Fig. 9.5 Uterine cavity and endometrium after negative pressure
suction and keep a full bladder so as to facilitate ultrasonographic
monitoring during operation.
2. Mechanical pretreatment: Prior to TCRE, negative pres- 9.2.2.8 Operator’s Preparation

sure suction can thin the endometrium (Fig. 9.5). Maia Prior to operation, the operator should check all the main
reported that the postoperative improvement of menstrua- devices and their functions, such as transparency of the tele-
tion in patients who received endometrial mechanical scope, flexibility of the operating handle, and whether con-
pretreatment was the same as those who received drug nectors of current generator, cables, and the electrode plate
pretreatment. are loose or not. If there is malfunction with the equipment,
it should be repaired timely prior to operation. Meanwhile,
9.2.2.5 Timing of Surgery there should be a sufficient number of wire loops for spare
1. After menstruation, the endometrium is at its early prolif- use.
erative phase and is <4 mm in thickness, which is the
ideal time for operation.
2. For those who have had endometrial pretreatment, the 9.2.3 Anesthesia
endometrium has been thinned or atrophied, operation
may also be performed at any phase of nonmenstrual The distribution of pelvic nerves is very suitable for local or
period. regional block anesthesia, under which TCRE can be per-
3. If there is an uncontrollable bleeding, emergency opera- formed. If operation time is short, intravenous anesthesia can
tion should be done. be applied (see Chap. 7). When choosing anesthesia, one
should take the following points into consideration.
9.2.2.6 Preparation on the Day Before Operation
1. Sterilization of hysteroscope and its equipment. 9.2.3.1 Choice of the Patients
2. A cervical osmotic dilator or a laminaria tent is inserted Some patients require general anesthesia because they would
into the cervical canal on the night before operation to not like to be conscious in the operating room. Some prefer
soften and expand the cervix (Fig. 9.6). When the inser- local anesthesia because they fear general anesthesia or want
tion is difficult, 100 mg rectal indomethacin can be used. to see the operating video.
Misoprostol 200–400 mg can also be given orally or be
inserted into posterior fornix of the vagina at night before 9.2.3.2 Choice of the Operators
or 4 h prior to the operation. Alternatively, phloroglucinol It depends on the degree of training, experience of regional
injection can be applied by intravenous drip 30 min prior anesthesia, and desire of the operators in free talk with the
to operation with a dosage of 80 mg. students.
194 E. Xia et al.
9.2.3.3 Operation Duration able for patients with narrow and small uterine cavity and
The effect of local anesthesia may last a maximum of 2 h. If having an expected longer operation time. Hypertension
the expected operation time lasts over a long period, such as and glaucoma are contraindications.
surgery with multiple or large myomas, general anesthesia 3. Epidural anesthesia: Patients with contraindications of
will be more suitable. intravenous anesthesia or more complex operation may
choose epidural anesthesia, which is functionally reliable
9.2.3.4 Combined with Laparoscopy and satisfying in muscle relaxation. With a top-up in epi-
Diagnostic laparoscopy can be applied under local anesthe- dural anesthesia, the time can be arbitrarily extended. If
sia. However when the patient wakes up, she may experience operation can be completed within 1 h, single epidural
a discomfort from pneumoperitoneum, shoulder pain from anesthesia is preferred.
diaphragmatic irritation, and breathing difficulties caused by 4. General anesthesia: It is a closed-circuit inhalation anes-
excessive head-down position. If so, she should choose gen- thesia with tracheal intubation following intravenous
eral anesthesia. induction with succinylcholine, with the advantages of
clear airway and sufficient oxygen supply. General anes-
9.2.3.5 Day Surgery thetic is given by intravenous drip, which can control the
A patient performing TCRE often doesn’t need to stay over- drop speed, and muscle relaxants can be added. The effect
night in hospital, especially when the pain and nausea are of anesthesia is satisfactory, and both ECG and blood
controlled. She can be discharged from hospital after surgery oxygen saturation are monitored, so it is relatively safe.
on the same day. It is suggested that a day surgery should be The patients with obesity and hernia are not suitable for
performed under intravenous anesthesia, and operation time this anesthesia.
shouldn’t exceed more than 30 min.
9.2.3.6 Complications 9.2.4 Operative Procedures

Epidural anesthesia should not be applied in patients with
arrhythmia and hypertension. The commonly used anesthetic 9.2.4.1 Transcervical Resection of Endometrium
methods are as follows. (TCRE)
1. Examine the uterine cavity. If endometrium is found to
1. Local anesthesia: The afference of the pain originated be thick, suction aspiration can be first used (Fig. 9.7a,
from the uterus is transmitted from the cervix into the b).
spinal cord through the second, third, and fourth sacral 2. First, use vertical electric wire loop to resect the uterine
nerve root. The operator may administer cervical block fundus (Fig. 9.8). The resecting depth reaches the super-
anesthesia or intrauterine injection with 1% lignocaine ficial myometrium beneath the endometrium (Fig. 9.9),
containing adrenalin 1:200,000. After the hysteroscope is with a blended current at the power 80–100 W. Rollerball
placed in the uterine cavity through the dilated cervix, a electrode can also be used to coagulate the endometrium
fine needle is inserted under direct vision into the proxi- of uterine fundus (Fig. 9.10).
mal muscle of uterine cornua, and a local anesthetic about 3. A 90° wire loop or band electrode (Figs. 9.11 and 9.12a,
40 mL is injected. Uterus and cervix are rich in blood b) is used to resect the endometrium and underlying
vessels, so in the process of injection, the operator should superficial myometrium starting from uterine fundus in
always suck back in order to avoid intravascular injec- a downward direction and clockwise or counterclock-
tion. Although when the above tests are negative, some- wise sequence (Figs. 9.13, 9.14, 9.15, 9.16, and 9.17).
times the patient may also have transient bradycardia, 4. The resection of the endometrium and the superficial
elevated systolic blood pressure, and pale face, so the myometrium usually starts with the posterior wall of the
patient should have ECG and blood pressure monitoring. uterus in sequence (Fig. 9.18). If the resection termi-
Patients with mental stress may be given sedatives. nates at 1 cm lower to the internal os of the uterus, it is
2. Compound intravenous anesthesia: Intravenous anesthet- called total resection of endometrium (Fig. 9.19); if it
ics like ketamine, propofol, and sevoflurane are injected terminates at 1 cm higher above the internal os, it is
via veins, acting on the central nerve system through called partial resection of endometrium (Fig. 9.20).
blood circulation, and produce general anesthesia. This 5. Generally, the moveable distance of electric wire loop is
method is rapid in induction, has no stimulation to the confined within 2.5 cm when resecting. First resect
respiratory tract, and can make the patients feel comfort- upper 1/3 of the endometrium, then resect middle 1/3. If
able. But it is poor in muscle relaxation, so it is not suit- total endometrial resection is to be done, lower 1/3 of the
a b
Fig. 9.7 (a) Uterine cavity prior to TCRE. (b) Uterine cavity after suction aspiration
Fig. 9.8 The endometrium at the uterine fundus resected by vertical Fig. 9.9 Superficial myometrium visible after resection of the endo-
wire loop metrium at the uterine fundus
endometrium shall be resected until the cervical canal. obstructing the hysteroscopic view. A small amount of
When an oval forceps is used to clamp tissue fragments endometrial fragments can be discharged spontaneously
out of the cavity, the irrigation fluid has to flow out several days after operation. If the operator is skilled and
through the cervical canal. Each distension and collapse proficient, he can increase the resecting distance through
of uterine cavity may cause uterine bleeding, thus moving the resectoscope from the uterine fundus to the
196 E. Xia et al.
Fig. 9.10 The endometrium at the uterine fundus electrocoagulated by Fig. 9.11 Wire loop electrode
rollerball electrode
a b
Fig. 9.12 (a, b) Band electrode
uterine isthmus, and take out the resected tissue strips electrocoagulation hemostasis (Fig. 9.24), and examine
immediately (Figs. 9.21 and 9.22). the uterine cavity (Fig. 9.25).
6. After the uterine cavity is made empty, put back resecto- 8. After TCRE, a light brown cylinder-shape uterine cavity
scope to check and resect the residual endometrium. is formed (Fig. 9.26).
7. When operation ends, reduce the uterine distension 9. Endometrial fragments are sent for histological
pressure, observe the bleeding points (Fig. 9.23), apply examination.
Fig. 9.13 Electric resection of the endometrium and superficial myo- Fig. 9.15 Electric resection on right posterior wall
metrium on the posterior wall
Fig. 9.16 Electric resection from posterior wall to left lateral wall and
Fig. 9.14 Electric resection on right lateral wall then anterior wall
trium of both cornua, which are the thinnest of myo-

10. Precautions metrial layer. When resecting the endometrium at
(a) It is the most difficult to resect and easy to perforate the uterine cornua, the operator must shave shallow
at the fundus, therefore the operator must be very each time until all the endometrium is removed
careful not to push the wire loop too far into the completely, which is at a less risk of perforation
myometrium, especially in resecting the endome- than that of a deep cut.
198 E. Xia et al.
Fig. 9.17 Uterine cavity after a total resection of endometrium Fig. 9.19 Total resection of endometrium
Fig. 9.18 Starting from uterine fundus, resect endometrium of poste- Fig. 9.20 Partial resection of endometrium
rior wall, and then resect in a counterclockwise direction
reach the desired depth by no more than one

(b) The depth of the resection depends on the endome- resection.
trial thickness, and the aim is to resect endometrium (c) When distending pressure is insufficient, the bilat-
and its 2–3 mm underlying myometrium (Figs. 9.27, eral walls of uterus can be closed, both sides of the
9.28, and 9.29). This depth is sufficient to remove uterine cornua may appear deeper, and often with
the full layer of endometrium except for the remnants of the endometrium, so when operation
extremely deep endometrium, and superficial myo- ends, the operator should elevate the distending
metrium which avoids resecting the large vessels. pressure, inspect and resect the residual endometrial
And if the endometrium has been pretreated, it could tissue (Fig. 9.30).
Fig. 9.21 Resected endometrial tissue strips by TCRE Fig. 9.23 Reduce the uterine distension pressure and observe the
bleeding points
Fig. 9.22 Words formed with the resected endometrial tissue strips by
TCRE
(d) After the resection of endometrium and its superfi-

cial myometrium, if pink or bright red endometrial
tissue in a trumpet-flower shape appears in the
resected myometrial surface, it will be the focus of
adenomyosis (Fig. 9.31). Fig. 9.24 Electrocoagulation of the bleeding point by rollerball
(e) If the endometrium is thicker, electrocoagulation electrode
can be repeated following the electric resecting, by
which the efficacy can be improved (Fig. 9.32). 9.2.4.2 Endometrial Ablation (EA)
(f) It has been confirmed by research data that the more 1. Laser: The preparation before inserting a hysteroscope
extensive the resection is, the bigger proportion of is the same as TCRE. When it has a clear vision under
patients achieving postoperative amenorrhea or hysteroscope, insert a quartz laser fiber with a flexible
hypomenorrhea will be. At present, it is rare to have metal protective sheath into its operative channel. There
partial resection, and the internal orifice of uterine are two kinds of operative modes: dragging and blanch-
cervix is regarded as the lower bound of resection by ing, with power of 55–80 W. During the operation, the
most scholars. color of the endometrium may change from pink to pale,
200 E. Xia et al.
Fig. 9.25 Uterine cavity after TCRE Fig. 9.27 Resection to a depth of 2–3 mm beneath the endometrium
Fig. 9.28 Endometrium lining uterine wall prior to surgery

Fig. 9.26 A light brown cylinder-shape uterine cavity after TCRE
ing the monitor. The operator can drag the laser fiber
brown, and then black (carbonization). Tubal ostium is back with right hand, and lift up or push down the proxi-
the hardest to visualize, which is also difficult for laser mal end of hysteroscope with left hand so as to control
fiber to reach. From the tubal ostium the ablation of the laser fiber in touching or focusing on the endome-
endometrium starts, and extends gradually to the uterine trium to be destroyed. After treatment of uterine fundus,
fundus, and gets together at the midline. The hystero- ablate the endometrium in the uterine anterior, bilateral
scope should always be maintained at the 12 o’clock and the posterior wall until the internal orifice of uterus.
position, never turning. It is important to keep its direc- In order to reduce the risk of cervical stenosis, some
tion when an operator performed an operation by watch- operators stop the ablation at a few millimeters above
Fig. 9.29 At the end of resection, it removes the full layer of endome-
trium and superficial myometrium, which reaches the cervical internal Fig. 9.31 The residual endometrium with bright red color in trumpet-
orifice flower shape after endometrial resection is seen in myometrium on pos-
terior wall, which is the foci of adenomyosis
Fig. 9.30 Electric resection of endometrium at right uterine cornu

Fig. 9.32 Rollerball coagulation following endometrial resection, with
the bubbles caused by tissue vaporization collecting above the
the internal orifice. There are also operators who do not rollerball
use hysteroscopy but place the laser fiber directly into
the uterine cavity under ultrasonography guidance to 2. Electrocoagulation: The preparation before inserting a
destroy the endometrium, which has the same therapeu- hysteroscope is the same as TCRE. Those who do not
tic effect. The shortcoming of this method is that the have endometrial pretreatment should administer uter-
endometrium specimens cannot be obtained for histo- ine suction aspiration to suck out the functional layer of
logic examination. the endometrium as much as possible, so that a com-
202 E. Xia et al.
plete ablation could be ensured. Press lightly the roller- should be spent at the same point before the electrode is
ball (Fig. 9.33)/roller barrel electrode (Fig. 9.34) in moved. The time required is to wait for the tissues
contact with tissues, and step on the electrocoagulation around the electrode to turn white, about less than 1 s.
pedal to turn power on, with the power 40–60 W. Due Once the tissues surrounding electrode become white,
to the amount of thermal damage on tissues by elec- then move the electrode slowly towards the cervix.
trode coagulation being relatively high, a short time When moving, the tissue destruction zone is visible in
front of the electrode, and by this way the rolling speed
of the electrode is monitored. Electrocoagulation of the
endometrium on each wall should be done in a sequence.
As it is easy to produce bubbles, usually start from the
anterior wall (Fig. 9.35). It is difficult to roll the elec-
trode at the uterine fundus and tubal ostia, so electrode
can be placed at a point when doing electric coagulat-
ing, and then retract a bit, repeat it several times until
electrocoagulation is fully achieved in the fundus and
the adjacent cornua. Remember not to push the elec-
trode to the tubal ostium. Electrocoagulation should
terminate at the internal cervical ostia, which are some-
times difficult to discern. Hence 10–20 mL diluted
methylene blue solution is injected into uterine cavity
before dilating the cervix, so that the operator can see
the endometrium blue-stain, uterine tubal ostium dark
blue spot, and cervical canal blue parallel lines. Because
the electric coagulation changes the appearance of
endometrium, it is difficult to detect the residual endo-
metrium without coagulation. The shape of endometrial
surface after electrocoagulation helps to find adenomy-
osis. Since the tissue rich with cells has better conduc-
Fig. 9.33 Electrocoagulation of endometrium by contact of rollerball
electrode with the endometrium tivity than the fibrous tissue, the endometrium has
Fig. 9.34 Roller barrel electrode Fig. 9.35 Rollerball coagulation of endometrium at the anterior wall
lower impedance than the uterine myometrial tissue, 9.2.5 Intraoperative Complicated Conditions
and is damaged more thoroughly than the surrounding and Managements
muscle tissue. Therefore, there are transverse slots at
locus of adenomyosis and the operator may sense a 9.2.5.1 Inadequate Distension of Uterine Cavity
feeling of collision when the electrode rolls. As the Inadequate uterine distension is the most common problem,
endometrial glands are located deep in the myometrial especially those who do not use uterine distending pump.
layer, gland tissues cannot be entirely coagulated, so it When the uterine cavity is not properly distended, the uterine
needs resection with wire loop at this site. fundus and tubal ostia are hard to be seen. It is important to
adequately expand the uterine cavity with distending fluid to
Vercellini et al. made a comparative study of EA with clearly see the whole cavity, and the operation can begin.
vaporizing electrode (Fig. 9.36) and TCRE with wire loop. Otherwise, it may cause insufficient resection and uterine
The measures included the absorption of distension fluid, perforation. The common reasons of inadequate uterine dis-
operating time, and the difficulties of surgery. The result was tension are cervical incompetence, perforation of the uterus,
that the mean ± the standard deviation (SD) distension fluid and low uterine distending pressure. Due to the low intra-
deficit was 109 ± 126 mL in the vaporization group and uterine pressure, the perforation is often accompanied by
367 ± 257 mL in the resection group, P < 0.001, and there bleeding. For cervical incompetence, suture or cervical
were no differences in other measures. clamp can be applied to occlude the cervix. If uterine perfo-
Romer and Schwesinger made a retrospective analysis of ration is suspected, stop operation immediately and examine
40 cases who received pretreatment of the endometrium with abdominal symptoms, and observe whether or not there is
gestagen, danazol, or GnRH analog, which were compared free liquid around the uterus and in abdominal cavity by
with control group. The measurements evaluated by surgeons ultrasonography. In cases of low distending pressure, it
include the thickness of endometrium and the depth of coag- should be elevated, and if there is no distending pump, it can
ulating damage. The result was that 90% of the cases in dan- be solved by using three way pipes, raising the height of irri-
azol group and GnRH-a group had adequate endometrial gating fluid container, or increasing the volume of the irrigat-
atrophy. The histological examination revealed atrophic ing fluid. Sometimes the inadequate uterine distension is
endometrium or a small amount of proliferative endome- caused by uterine contraction, to which intravenous injection
trium. In a 2-year follow-up of EA, there were higher amen- of atropine can be applied. Notably, some uterus would not
orrhea rates in danazol group and GnRH-a group. It was respond to the above managements, the main causes might
considered that endometrial pretreatment should be done be too small uterine cavity, uterine fibroids, and adenomyo-
prior to EA. sis. Poor uterine distention might also happen when flow
inlet and outlet valves are obstructed, there are blood clots
between the inner and outer sheath, the inflow pipe is folded,
or air inflow of irrigation container is obstructed.
9.2.5.2 Slow Clearance of the Fragments

and Clots Inside the Uterine Cavity
If tissue fragments and blood clots are blocked at the channel
between the inner and outer sheaths, the sieve of outer sheath,
or inflow valve, or if the outflow suction pressure is insuffi-
cient, the fluid cannot flow out smoothly, thus causing irriga-
tion fluid circulation inside the uterine cavity to slow down,
and leading to the delay of debris and clots clearance, which
affects the field of view and operating process. It can be
solved immediately by increasing suction pressure and
cleaning the endoscopic sheaths.
9.2.5.3 Insufficient Resection

If the resected tissue is not cut off, the tissue blocks may float
like large polyps in the uterine cavity. The most common
reason is that the wire loop has not yet returned to the sheath
when power is switched off. If so, the operator should check
whether the wire loop has broken or deformed. If the
Fig. 9.36 Vaporizing electrode deformed wire loop cannot return to the sheath when the
204 E. Xia et al.
resection ends, the operator can use a finger to push inward increase irrigation fluid absorption. The operation should be
gently and make it return to the sheath. In addition, if the completed as quickly as possible if there is no uterine perfo-
resecting current intensity is too low, it may also lead to ration. In addition, attention should also be paid to whether
incomplete resection, which can be solved by increasing the there is leakage of irrigation fluid or not and that the irriga-
current power. tion fluid may not be irrigated into the uterine cavity when
uterine distending pressure is too high.
9.2.5.4 Unclear Observation of the Endometrium
and Uterine Cavity 9.2.5.6 Intraoperative Bleeding
In addition to the factors including inadequate uterine disten- The low uterine distending pressure, insufficient electroco-
sion and slow clearance of intrauterine debris and blood agulating current intensity, too deep of the resection, and the
clots, the resected fragments, the bubbles under anterior uter- resection of uterine fibroids may all cause bleeding, which
ine wall and fibroids protruding into the uterine cavity may hinders the operation. The solution to it is to raise the uterine
all obstruct the vision (Figs. 9.37 and 9.38).The interference distending pressure, increase the electrocoagulating power
of tissue debris is a trouble before the operator learns to push of the blended current and coagulate the bleeding vessels.
the tissue fragments to gather together at the uterine fundus. The vascular layer of uterine myometrium lies 5–6 mm
The operator can remove the tissue fragments before resect- beneath the endometrium, through which there are more ves-
ing again, or move the lens body downward to resect along sels passing. Therefore, when the resection reaches into the
tissue and take it out immediately. Increasing suction pres- vascular layer, it can cause massive bleeding. Therefore the
sure or adjusting patients’ position may contribute to expel depth of resection should be above the vascular layer. If there
the bubbles under the anterior uterine wall. For intrauterine is myoma bleeding, the vessels can be coagulated around the
fibroids interfering with the vision, only total or partial pseudo-capsule.
removal can make a clear vision.
9.2.5.7 Postoperative Hemorrhage
9.2.5.5 Too Rapid Absorption of Irrigation Fluid Common reasons of postoperative bleeding are too deep
The causes of it include too high distending pressure and resection, infection, and tissue debris remaining in the uter-
perforation of the uterus. When the fluid overload is detected, ine cavity. The solution is to place balloon catheter in the
the operation should be terminated immediately, and check uterine cavity to stop bleeding by compression, administer
whether there is perforation of the uterus or not. After the antibiotics, and empty the intrauterine residues, and mean-
perforation is excluded, operation can be continued. Cervical while, contraction agents and hemostatic agents can be used.
laceration and incomplete uterine perforation may also The balloon catheter should be taken out after 4–6 h of usage
Fig. 9.37 Bubbles under uterine anterior wall interfere with the vision Fig. 9.38 Uterine cavity after the discharge of bubbles
because prolonged placement may lead to necrosis of uterine and blood sodium is reduced by 15 mmol/L and
myometrial wall. above compared to that prior to operation, the opera-
tor should be on the alert.
(d) Plasma osmotic pressure: The absorption of irriga-
9.2.6 Intraoperative and Postoperative Care tion fluid often leads to a decrease in plasma
osmolality.
9.2.6.1 Intraoperative Monitoring 3. Ultrasonography monitoring: According to Xia et al.,
Close monitoring during TCRE and EA is mandatory. when beginners perform TCRE procedure, ultrasonogra-
Considering the operation time, incision, hospitalization phy monitoring (Figs. 9.39, 9.40, 9.41, and 9.42) should
time, TCRE, and EA seem to be minor, but are still major be used alongside. Only when the electric resecting tech-
operations regarding their potential risks. Operation safety nique is proficiently grasped, the depth of resection can
must always be the first consideration, and intensive moni- be precisely controlled, especially for those with medical
toring is an important component. Operators and other staff pretreatment to thin the endometrium prior to operation,
should always be alert and warned about two main risks, may TCRE surgery be done without monitoring, but
namely uterine perforation and fluid overload, which may mainly through observation under hysteroscope.
never occur to experienced surgeons under normal circum- 4. Laparoscopic monitoring: In order to reduce the irrigat-
stances, but are potentially dangerous for beginners. ing fluid absorption, bilateral fallopian tube may be
ligated under laparoscopy. Since laparoscope cannot be
1. Routine monitorings: used to monitor the posterior wall of the uterus, there are
(a) Symptoms and signs: They include chest discomfort, fewer applications at present.
nausea and vomiting, irritability, lethargy, purple,
pale, facial edema, etc. 9.2.6.2 Postoperative Care and Managements
(b) Heart rate and blood pressure: The patients who have 1. If antibiotics are not administered during operation, intra-
underlying coronary heart disease and hypertension venous administration of antibiotics could be given to
are likely to develop hypertension and tachycardia prevent infection on the first day after operation.
before anesthesia, and hypotension may occur during
anesthesia and operation. And those having massive
blood loss are often accompanied by tachycardia and
hypovolemic shock. When there is excessive absorp-
tion of irrigation fluid, the systolic blood pressure is
on the high side, the heart rate slows down, and pulse
pressure is broadened.
(c) Body temperature: When a large volume of irrigation
fluid flows into the uterus, the body temperature will
drop, and if the operation time is longer, it is possible
to develop chills and shivering.
2. Special monitorings:
(a) ECG and cardiac function monitoring: It may be
applied to those who have cardiac and renal
insufficiency.
(b) Hemoglobin and hematocrit: Due to irrigation fluid
absorption and blood loss, the levels of hemoglobin
and hematocrit drop, which may take place about
20 min after the start of electric resection.
(c) Serum potassium and sodium: Irrigation fluid absorp-
tion can dilute blood, and also have effects of osmotic
diuresis and natriuresis. Operation injury also allows
sodium ions to migrate into the cells, thus the intra-
operative blood sodium decreases by varying degrees.
The degree of hyponatremia is related to the duration
of operation, the volume of the irrigating fluid, and
the weight of the resected tissues. If the patients
develop nausea, vomiting, dizziness, dysphoria, etc., Fig. 9.39 Ultrasonography monitoring (prior to operation)
206 E. Xia et al.
Fig. 9.40 Ultrasonography monitoring (irrigation fluid into the uterine Fig. 9.42 Ultrasonography monitoring (ends of the resection)
cavity)
2. Observe the body temperature, blood pressure, pulse,

heart rate, and reactions during anesthesia recovery
period and moving the patients. More intraoperative
bleeding and hypovolemia may cause hypotension. If the
temperature of distension fluid during operation is too
low, the patients may develop hypothermia and shivering
after operation, and warm-keeping measures should be
taken.
3. Bleeding: Oxytocin and (or) triplet hemostatic agents
may be administered: intravenous drip of 5% glucose
solution 500 mL + vitamin C 3 g + dicynone 3 g + pamba
0.3 g. If there are cases with acute active hemorrhage, a
balloon catheter can be placed into the uterine cavity, and
a certain amount of sterile saline is injected into the bal-
loon until the bleeding stops, usually about 8–20 mL. If
necessary, electrocoagulation hemostasis should be
applied via hysteroscope.
4. Diet: The postoperative reaction to anesthesia often
causes nausea, vomiting, etc., thus the patient should fast
for 6 h.
5. Attention to electrolyte and acid-base balance: Sodium
is the most important cation of extracellular fluid, which
accounts for more than 90% of the total number of
extracellular fluid cation. If its content is changed, it
will have definitive effects on the total cations. If severe
hyponatremia occurs during operation, there is often
metabolism disorder of hydrogen ion, and acid poison-
Fig. 9.41 Ultrasonography monitoring (beginning of the resection)
ing may occur. Thus much attention should be paid to pearance of reflexes, weak pulse, decrease in blood
monitoring and timely correction. According to the uro- pressure, and even shock.
logical statistics, more than 80% patients who had the 6. Treatment of hyponatremia:
transurethral resection of prostate developed different (a) Mild: The patient may lack about 0.5 g sodium per
degrees of hyponatremia, which was TURP syndrome. kilogram body weight. Intravenous administration of
According to its degree and speed, it can generally be 5% glucose and saline 2000–3000 mL can be used. If
divided into 3°. the patient’s cardiac function is normal, 1000 mL can
(a) Mild degree: The serum sodium is at 137– be given at the first hour, then slow down. Afterwards,
130 mmol/L, both intracellular and extracellular fluid the speed of intravenous drip is regulated by check-
is hypotonic, and the patients may develop dizziness, ing the serum sodium concentration.
headache, fatigue, unresponsiveness, and loss of (b) Moderate and severe: The patient with moderate
appetite. hyponatremia may lack about 0.5–0.75 g sodium per
(b) Moderate degree: The serum sodium is at 130– kilogram body weight, and about 0.75–1.25 g with
120 mmol/L, the above symptoms may become more severe hyponatremia. For patients with moderate and
severe, and nausea, vomiting, skin relaxation, a severe hyponatremia, it is proper to use hypertonic
decrease in neural reflex, and decline of blood pres- saline instead of normal saline. Hypertonic saline
sure may develop. may increase the cellular osmotic pressure, transfer
(c) Severe degree: The serum sodium is below the water within the cell to extracellular and reduce
120 mmol/L. Both nausea and vomiting may be cell swelling, thus restoring blood osmotic pressure
developed seriously, the patient may also develop to normal. The commonly used is 3 or 5% sodium
dazing, faint, and coma in the end. Its clinical mani- chloride solution.
festations include lack of muscular tension, disap- Its supply is calculated by the following formula:
In which * refers to the total body fluids accounting for compress of the local infusion contributes to the preven-
52% of the body weight. tion of thrombotic phlebitis.
For example: If the patient’s body weight is 60 kg, the 7. Treatment of hypokalemia
measured serum sodium is 125 mmol/L. The sodium Generally speaking, if the patient has normal renal
amount requiring to be supplemented = (142 − 125 mmo function, there is no change in blood potassium during
l/L) × 52% × 60 = 530.4 mmol. operation. However, if the water intoxication occurs and
Since the sodium ions in 5% sodium chloride solution diuretics is used, one must pay attention to whether there
of each mL is 0.85 mmol, the required 5% sodium chlo- is low potassium levels during operation, and if there is,
ride solution = 530.4/0.85 = 624 mL. one must correct it in time.
On the supply of hypertonic sodium chloride solution,
the operator should pay attention to the following points:
(1) Give 1/3 or 1/2 of the total at the very beginning, and 9.2.6.3 Postoperative Care
then the rest of the supplement is determined according to In patients suffering from uterine cramps following opera-
the patient’s consciousness, blood pressure, heart rate, tion, painkillers or prostaglandin can be taken for pain relief
rhythm of the heart, pulmonary symptoms and changes of after urinary retention being excluded. A minority of patients
serum sodium, potassium, and chloride. (2) Regarding may have transient fever, which can be treated by using indo-
hyponatremia, be sure not to transfuse a great amount of methacin suppositories 100–200 mg per rectum and (or) tak-
solution without sodium, and then transfuse with sodium. ing oral liquid of 10 mL Radix Bupleuri with the temperature
This is because after a great volume of fluid transfusion, dropping in 24 h. After operation, the patients may have a
the serum sodium will be made lower, more water moves little vaginal bleeding, which is known as bloody serous fluid
into the cell from outside and makes them swell, thus discharge within 2 weeks and simple serous fluid discharge
worsening the symptoms. (3) The intravenous drip of in the following 4–6 weeks. For the patients who have abnor-
hypertonic saline is easy to stimulate the local venous mal vaginal discharge, massive or prolonged vaginal bleed-
intima, causing venous thrombosis. Therefore, a warm ing, uterotonic agents, hemostatic agents, and antibiotic
208 E. Xia et al.
medication can be administered. Three months after and metabolic acidosis, which worsen the heart
operation is the time of the return of menstruation, and those failure and cause shock or severe ventricular
who have no bleeding by then have suffered loss of men- arrhythmias and death.
struation (amenorrhea). • Water intoxication and hyponatremia: The electro-
lyte components of the extracellular fluid are
diluted. Since the main component of electrolyte is
9.2.7 Detection and Management sodium, its concentration decreases, thus hypona-
of Operational Complications tremia develops. Water intoxication is the most
harmful to the cerebral nerve tissues. When the
Due to the large operational surface in TCRE or EA, there serum sodium reduces to below 125 mmol/L, water
are more operational complications. Bratshi reported that the begins to enter the brain cells, which increases the
incidence of operation complications was 2.5% in 465 cases water content within the brain cells, and the patients
who had TCRE. Therefore, be sure not to violate patients’ may present with nausea, vomiting, drowsiness,
will to perform this operation by force. headache, diminution or loss of tendon reflexes.
During coma, some patients may have positive
9.2.7.1 Intraoperative Complications Babinski syndrome, and sometimes develop hemi-
1. Uterine perforation: The difficulties of TCRE procedures plegia. When it is severe, the brain cells swell, and
are that if the resection is too shallow and fail to reach the intracranial pressure increases, which may cause a
basal layer, subsequent endometrial regeneration will variety of neurologic and mental symptoms, such
lead to the recurrence of abnormal bleeding, indicating as gaze, aphasia, alienation, directional disorder,
the failure of the treatment. However if the resection is drowsiness, dysphoria, muscle twitching, or even
too deep, uterine perforation may occur. Therefore, the convulsions and coma. Severe cerebral edema can
principle of TCRE is to give a cut to every location, develop the foramen magnum herniation or trans-
including endometrial functional layer, basal layer and its tentorial herniation, leading to breath-cardiac
underlying 2–3 mm myometrium, and the operator should arrest, and resulting in death.
be very prudent when giving a second cut. When EA is (b) Treatment:
being done with the power on, the rollerball or vaporizing • Diuretic: It is used to relieve the burden of heart,
electrode must keep rolling, and its in situ stay can lead to and remove the redundant water out of the body.
too deep coagulation of myometrial layer, and even coag- • Treatment of hyponatremia: In emergency circum-
ulation of full layer. If the high heat of electricity spreads stances, besides of furosemide being given, intra-
to the bowel or bladder adjacent to the uterus, intestinal venous injection of 5% hypertonic saline can be
fistula may develop after operation. given so as not to delay the rescue time, and there
2. TURP syndrome: Due to the large cutting surface of the is no need to wait for the report of serum sodium.
uterus by TCRE and more open veins, a large amount of • Treatment of acute left heart failure: Its treatment
irrigation fluid is absorbed into the blood circulation, may be done with digitalis.
resulting in a series of systemic symptoms caused by • Treatment of pulmonary edema: Generally, oxy-
hypervolemia and hyponatremia, and even death in severe gen is given via the nasal tube with defoaming
cases. The pathways through which the irrigation fluid agent, and the use of morphine is forbidden.
flows rapidly and abundantly into the circulation are • Treatment of brain edema: Bird et al. used high
mainly the open veins in the cutting surface, and sec- concentrations of urea. Urea is an osmotic diuretic,
ondly, fallopian tubes. Some scholars conducted ligation and its injection can make the osmotic pressure in
of bilateral fallopian tube under laparoscope prior to elec- intravascular fluid higher than that in tissue fluid,
tric resection in order to reduce the absorption by the sec- which promote the water moving from the edema-
ond way. Wood and Roberts, in order to reduce the tous brain tissue into blood vessels, then the cere-
transtubal absorption, occluded the bilateral fallopian bral edema can be relieved; corticosteroids can
tubes with silastic rings under laparoscope in nine cases also be used at the same time to stabilize the cell
prior to TCRE, with the result that mean fluid deficit was membrane and reduce capillary permeability, thus
259 mL (0–900 mL), which was lower than 643 mL relieving cerebral edema.
(100–2030 mL) reported by others. • Correction of electrolyte and acid-base balance
(a) Clinical manifestations disorders: When a diuretic is used, a large amount
• Hypervolemia: Its consequences are acute left of potassium may be passed with the urine,
heart failure and pulmonary edema, and if not which may cause low serum potassium and
promptly treated, it can further develop dyspnea arrhythmias.
(c) Prevention: Robert and Walton reported on a double blind trial under
• Intensive care should be given to cases with high local anesthesia with the paracervical injections of 10 mL
risks such as cases with large myomas, without of 0.5% bupivacaine and 1:200,000 adrenaline when
endometrial pretreatment, and those who have the TCRE began, with the result of significant reduction of
occurrence of uterine perforation. intraoperative blood loss (P < 0.005) and slight reduction
• When the fluid deficit is to 1000–2000 mL, mild of postoperative bleeding (P > 0.005). However, it was
hyponatremia may occur, and the operation should not suggested for routine use because the heart rate
be terminated as quickly as possible. When the increased in the drug used group (P < 0.005).
deficit is >2000 mL, the patient may develop 4. Venous gas embolism
severe hyponatremia and acidosis. Among the reported nine cases of gas embolism
• When there is acid-base balance disorder, one caused by hysteroscopic operation, five cases underwent
should immediately stop the operation. The total TCRE or EA operation (56%), of which 3 survived and 2
operation time should be controlled within 1 h. died.
• Try to take a low pressure irrigation.
• Operation time can be prolonged if the central 9.2.7.2 Postoperative Complications
venous pressure is measured. Complete endometrial ablation appears to be very safe in the
• If a myoma is larger, it can be resected in stages. short term; however, with the passage of time, some long-
• Once TURP syndrome is found, the operation term complications may emerge. The problem is the devel-
should be stopped as soon as possible. opment of postoperative uterine scar and contracture. Any
bleeding behind the persistent scar or from regenerated
Bennett et al. studied the methods to prevent TURP syn- endometrium may lead to problems because of obstruction,
drome. Twenty women were involved in the study group such as the intrauterine hematometra, uterine cornua hema-
with the pressure of fluid distention pump set below the tometra, PASS (postablation-tubal sterilization syndrome),
mean arterial pressure (MAPs) of the patients. In 20 women retrograde menstruation, and delayed diagnosis of endome-
of the control group, the pressure was set at random. It was trial carcinoma.
found that both the total volume and deficits of irrigation 1. Infection: Among the reported five cases of severe infec-
fluid in study group were significant less than those in con- tion following operative hysteroscopy, four cases under-
trol group, supporting the hypothesis that the pressure of went TCRE or EA, which accounted for 80%. In Loffer’s
fluid infusion pump should be set at or below women’s data, the incidence of postoperative infection in TCRE
MAPs. Baskett et al. conducted a study to compare two was 0.3%.
control techniques of irrigating fluid with the risks of fluid 2. Bleeding: In the two cases with persistent bleeding in
overload during operative hysteroscopy. In one group, pas- the late postoperative period in the Hysteroscopy Center
sive gravity outflow was used, and in another group, direct of Fuxing Hospital, Capital Medical University, both of
connection of the outflow to wall suction was used. The them were unresponsive to medical treatment, and cured
result was that the technique of connecting the outflow to by curettage, the scraped tissue was little, with granula-
wall suction reduced the risk of fluid absorption. It is gen- tion tissue confirmed by histopathological examination.
erally believed that the absorption of irrigation fluid in roll- 3. Uterine necrosis: Up to now, only one case of uterine
erball electrocoagulation of EA is less than that in wire necrosis has been reported being caused by HEAL.
loop electrode resection of TCRE. In 1999, Klinzing et al. 4. Intrauterine adhesions: After TCRE operation, all sur-
reported a case of a 45-year-old woman, who developed faces in the uterine cavity is denuded, and its anterior
severe hyponatremia after endometrial ablation with roller- and posterior walls are easy to adhere to each other.
ball electrode. After irrigating the uterine cavity with 10 L 5. Intrauterine hematometra: Turnbull’s reported on 59
of mixed solution including 2.7% Sorbitol and 0.54% cases who had magnetic resonance examination after
Mannitol for 45 min, she developed pulmonary edema and TCRE. It was found that most of patients who had amen-
severe hyponatremia. orrhea and all of patients who had menses had residual
3. Bleeding endometrium, and the residual endometrium could not
The vascular layer of the uterine myometrium lies communicate with the uterine cavity, which might lead
5–6 mm beneath the endometrium, and is mostly com- to hematometra formation, tubal dilatation, and perito-
posed of circular muscular fibers with fewer oblique mus- neal cavity effusion.
cle fibers, through which plenty of blood vessels are 6. Abdominal pain: Mints et al. reported that 11% of the
running. In TCRE, attention should be paid not to injur- cases after TCRE developed postoperative abdominal
ing the vascular layer. When the operation ends, the pain, which might be caused by intrauterine adhesions,
bleeding point of pulsatile artery is coagulated. Recently, intrauterine hematometra, and adenomyosis resulting
210 E. Xia et al.
from the active endometrial cells being squeezed into by removing the uterus after laparoscopic diagnosis.
myometrial layer under intrauterine pressure during Cervical pregnancy occurred in one case who developed
TCRE. massive bleeding during suction evacuation. Tubal preg-
7. Post-ablation-tubal sterilization syndrome (PASS): The nancy occurred in two. Only one case of intrauterine
patients with PASS all had the history of TCRE after pregnancy progressed to term and cesarean section was
sterilization. performed, with a small-for-date infant delivered and a
8. Adenomyosis: Some scholars proposed that trauma to subtotal hysterectomy performed because of placenta
the uterine myometrium by endometrial ablation might increta. It indicated that the incidence of postoperative
cause this disorder. ectopic pregnancy after TCRE was high (12.5%), and
9. Pregnancy: There have been reports of postoperative the incidence of complications including difficult surgi-
uterine pregnancy or ectopic pregnancy after cal termination, placental increta, fetal growth restric-
TCRE. Baumann et al. first reported a successful preg- tion, and the abnormalities of the third stage of labor is
nancy after TCRE and bipolar electrocoagulation of high. Therefore these women should be regarded as
tubal sterilization with good results. Pugh et al. reported high-risk populations and intensive surveillance should
one case of successful intrauterine pregnancy after be offered.
EA. Pinette et al. reported one case of successful preg- 10. Malignant lesions of endometrium: TCRE is a new pro-
nancy after YAG laser treatment. The damaged myome- cedure to treat nonmalignant abnormal uterine bleeding,
trium may cause disastrous consequences in late and its data for long-term prognosis are limited and the
pregnancy. Therefore, one should minimize the endome- incidence of endometrial cancer after surgery is
trial residues and unnecessary myometrial damages dur- unknown. In 2000, Brooks-Carter et al. reported one
ing operation. TCRE/EA has been so widely used in the case of 55-year-old women, to whom EA was applied
treatment of AUB that many women of childbearing age for the treatment of AUB after the uterine malignant
choose TCRE/EA, but it may increase obstetric compli- lesion being excluded. Five years later, she developed
cations significantly, so patients should be informed that the same symptoms and was histologically diagnosed as
desire of fertility is a contraindication. In 2005, Mukul well-differentiated adenocarcinoma (stage 1). It was
et al. from the United States reported for the first time considered that the endometrial adenocarcinoma was a
that a 34-year-old parous woman got intrauterine adhe- neoformation because of the intervals and it seems
sion and pregnancy after endometrial ablation. She was unlikely for high-risk patients with endometrial ablation
admitted to hospital after 24 weeks pregnancy because to obscure the undiscovered malignant or delay the diag-
of the shortened cervical canal, multiple intrauterine nosis. Valle and Baggish reported that the residual endo-
adhesions, and multiple fetal malformations detected by metrium in eight cases after TCRE developed
ultrasonography. Two weeks later, premature rupture of endometrial cancer in later days, and all were detected in
membranes occurred, and the fetal heart appeared to time without intrauterine scar concealing the early
have variable deceleration and classical cesarean section symptoms of uterine bleeding after TCRE. In 2005,
was performed. The fetal multiple malformations were Sagiv et al. from Israel reported that one woman who
caused by intrauterine adhesion after EA. In a retrospec- had EA due to DUB was found to develop endometrial
tive analysis of 1621 procedures of TCRE from 1990 carcinoma 3 years later. Since TCRE/EA cannot remove
May to 2005 January in the Hysteroscopy Center made all layers of the endometrium, even though there was a
by Xia et al., 32 women with previous TCRE achieved rigorous screening prior to operation, the patient still has
39 pregnancies, including one case of spontaneous mis- the risk of endometrial cancer after operation, even
carriage, 33 cases of artificial termination of pregnan- within 1 year.
cies, and five ectopic pregnancies. One case developing
significant intrauterine adhesion and stenosis after
TCRE underwent hysteroscopic adhesiolysis, followed 9.2.8 Experience and Evaluation of TCRE
by suction curettage and removal of the gestational sac.
One case had heavy bleeding about 700 mL after the After a survey of 5 years’ reports from different countries, a
gestational sac was aspirated by suction, with general successful TCRE and EA is defined as the volume of
treatment ineffective and bleeding controlled by insert- menstruation is reduced to normal, less, little, or even no
ing a Foley balloon to tampon the uterine cavity. One menstruation after treatment. Its success rate was from 90 to
case had right cornual pregnancy and subtotal hysterec- 95%. With the passage of time after operation, removal of
tomy was performed after a failed artificial suction. One uterus due to recurrence or diseases is on the rise slightly.
case had left cornual pregnancy and adenomyosis, with Among the recurrent cases, excluding those with endome-
hematometra obliterated by adhesions, which was solved trial carcinoma, a second or a third operation is feasible and
90% of the cases can avoid hysterectomy. As long as the tion. Tsaltas conducted a postoperative follow-up of 232
patient selection is proper, the success rate of TCRE will be cases of TCRE for 6 months to 6 years and 6 months, and
almost 100%, clinical satisfaction rate after operation found that the satisfaction rate was 78%, 13% had repeat
decreases slightly every year, and reoperation rate is 6.6%. endometrial ablation, and 17% had hysterectomy. Schiotz
reported that TCRE had a good effect in short term following
9.2.8.1 Effects of Operation the procedure in treatment of menorrhagia, and 20% under-
In 2001, Murdoch pointed out that hysteroscopic technique went hysterectomy in the long term. And it was reported in
had been applied widely with TCRE usually being regarded this paper that 324 cases had 348 TCRE procedures, of which
as a first-line treatment for DUB, with low mortality. Many 68 cases had fibroids resected simultaneously with a pro-
researchers pointed out that TCRE is highly effective in the spective follow-up of 1–8 years (mean 3.8 years), and reop-
treatment of menorrhagia. Although TCRE has been applied eration including TCRE or hysterectomy was classified as
for a shorter time than laser and rollerball electrocoagula- unsatisfied; three cases had uterine perforation (0.9%), with
tion, compared with other hysteroscopic techniques, its one case solved by laparotomy, 18 cases (5.2%) had hemor-
advantages are that this operation is faster, is possible to rhage, ten cases had fluid overload (2.9%), and five cases
resect the coexisting uterine fibroids, can provide the speci- (1.4%) had infection. Follow-up results showed 63 cases
mens for histological examination and has lower consump- (19.4%) had hysterectomy, of which 45 cases (67.2%) attrib-
tion and operation costs. Liu et al. from the Hysteroscopy uted it to pain partly or wholly. At the late research stage, 246
Center of Fuxing Hospital, Capital Medical University, cases in 260 were satisfied (94.6%). They concluded that
explored the influence of TCRE to every grade of uterine TCRE was a safe and effective method in the treatment of
artery hematodynamics, and the relationship between TCRE menorrhagia. Eighty percent of them might avoid major
and postoperative effect. They discovered that postoperative operations and some patients undergo operation just because
outcomes were related to the changes of postoperative uter- of pain, but this pain, being not typical, is difficult to diag-
ine hematodynamics with a better outcome in cases with nose from uterine origin. El Senoun et al. reported 91 cases
higher resistance of blood after surgery than prior to surgery. of EA from 1992 to 1997 for treatment of menorrhagia in
As for the long-term prognosis, the worldwide experiences women who were unresponsive to medication. Follow-up
suggested that among TCRE subjects, 70–90% are satisfied was conducted by questionnaire for at least 18 months
with the outcomes of treatment, of which 40–60% have (6–43), and 88% (80/91) responded. The prognostic indica-
amenorrhea after operation, 30–50% have menstrual reduc- tors included satisfaction rate, symptom relief rate, improve-
tion, 10–15% have normal menstruation, and the failure rate ment rate of health and life quality, etc. The results were that
is 5–12%. The analysis of 5 years of life table after operation 44% of cases (35/80) had amenorrhea, ten cases underwent
indicated that TCRE has made 80% subjects avoid further further treatment, including seven cases (9%) of hysterec-
operation and 91% avoid hysterectomy. Herman et al. tomy; 73% of cases had relief in periodic pelvic pain; 65%
reported 270 cases of hysteroscopic operation, with the result had improvement in premenstrual tension syndrome; 85%
that in a 4-year follow-up, only 5.6% of cases who had TCRE had improved work ability; 96% had improved sexual life;
needed a second operation, adenomyosis was not a good 99% returned to work in 4 weeks. Seventy-nine percent of
indication, and only 37% of cases did not require removal of patients were satisfied with treatment, 91% of patients would
the uterus. Xia reported 366 cases of TCRE with a follow-up like to recommend to friends. The author concluded that EA
from 3 months to 4 years, of which 16 cases underwent hys- technique was simple, effective, and an acceptable treatment
terectomy due to operation failure, 350 cases had improved for the selected cases. And its ultimate effectiveness needed
menstruation, with the success rate of the operation 95.6%. a long-term follow-up. Rosati et al. from Italy reported that
One hundred forty-six cases (41.7%) had amenorrhea fol- in 438 cases of premenopausal women without endometrial
lowing operation, of which 15 cases had a small amount of pretreatment, the rollerball electrode was used to coagulate
menses before amenorrhea; 119 cases (34%) had spotting, of the endometrium at the uterine fundus and uterine cornua,
which 22 cases had amenorrhea within 4–18 months after and then the wire loop electrode was used to remove the
operation; among 85 cases (24.3%) who were found to have endometrium in the rest of the uterine cavity, and finally the
adenomyosis during operation, 46 were followed up for rollerball electrode was used again to burn the uterine cavity
more than 3 months, of them 44 cases had menstrual with endometrium removed. An average follow-up was 48.2
improvement, two cases underwent hysterectomy, with the months, among those who responded, 47.8% had no men-
success rate 95.6%; in 46 cases with original dysmenorrhea, struation, 46% had little menstruation. One case (0.3%) had
postoperative dysmenorrhea disappeared or were relieved in EA again, 20 patients (5.2%) underwent hysterectomy, of
36 cases (78.3%). Yin reported 170 cases of EA, of which 70 which 15 cases (3.9%) failed in EA, and the other 5 patients
patients had dysmenorrhea prior to operation, and dysmenor- were unrelated with EA (endometrial atypical hyperplasia or
rhea disappeared or reduced in 38 cases (54%) after opera- uterine fibroids). Two hundred ninety-two cases (75.8%)
212 E. Xia et al.
were very satisfied and 78 cases satisfied (20.3%). There study, 25–40% of cases had a second operation within 5
were no major complications. During follow-up, 3 patients years after EA, most of which were hysterectomy. In
(0.8%) had pregnancy. The author believed that EA was a 2007, Furst et al. reported a study on follow-up of 61
safe and effective method in the treatment of premenopausal cases of EA and 59 cases of TCRE for 10 years, with 3%
menorrhagia and uterine bleeding, and could avoid 95% hys- loss of follow-up. There were no differences in prognosis
terectomy. However, patients should be informed about the between the two groups. Eleven percent had a second EA,
possibility of postoperative pregnancy and could not con- and 11% had a second TCRE; 22% had hysterectomy,
sider it as a contraceptive method. Munro reported that the mostly in 2 years. The author pointed out that the period
therapeutical effect of EA was not so ideal that 25–40% of of 2 years following EA was risk period for hysterectomy
cases had a second operation within 5 years after EA, which and thereafter, the probability of hysterectomy decreased
was often hysterectomy. Xia reported that 159 in 1431 cases to 6%.
(10.84%) were treated with drug therapy including hemosta- 3. Effect of TCRE and endometrial pretreatment: Donnez
sis, analgesics, antibiotics, progesterone, and endometrial et al. reported a prospective randomized double blind
inhibitor, of whom 37 cases underwent repeated TCRE study of goserelin pretreatment followed by EA for treat-
(2.59%); 87 cases (6.08%) had ultimately hysterectomy ment of DUB with a 3 years follow-up, in which there
because of recurrence of hemorrhage symptom, dysmenor- were 358 premenopausal women over 30 years old from
rhea, or uterine fibroids, of whom one case was found to have 37 centers of 12 countries. Goserelin was administered
early invasive cervical cancer, three cases were endometrial 3.6 mg, once per 28 days, for 8 weeks. EA was performed
adenocarcinoma, three cases got postablation-sterilization at about the sixth week when the endometrium was the
syndrome (PASS), four cases had voluntary removal of the thinnest. The amenorrhea rate of the third year after EA
uterus because of continuous dripping for half a year after was 21% in goserelin group and 14% in the control group
operation, 31 cases had uterine leiomyoma, which continued (P = 0.0571); 21% of cases in goserelin group had hyster-
to grow, 45 cases had uterine adenomyosis. The cure rate of ectomy, while there was 15% in the control group; 5.6%
operation was 93.92%. of cases in goserelin group and 2.1% in the control group
1. High-risk factors of TCRE failure: Raiga et al. studied the had the second EA. The conclusion was that there was a
risk factors associated with failed TCRE and found that higher rate of amenorrhea in goserelin group than that in
when it was followed up for 2–4 years, the results were control group. Tiufekchieva and Nikolov reported that
satisfactory, but there were problems of late recurrence. GnRH-a could reduce the endometrial thickness. Two
Both the enlarged uterus and adenomyosis increase the doses before TCRE could shorten the operation time and
failure rate, so it needs a long-term evaluation. produce a high amenorrhea rate; within 6–12 months
McCausland et al. thought that the deep adenomyosis after operation, the amenorrhea rate was 62.7% in medi-
(invasive depth >2.5 mm) was the main factor of TCRE cation group, while 27.2% in untreated group.
failure. 4. Relationship between the outcome of TCRE and the
2. High-risk factors for hysterectomy after TCRE: Dutton patients’ ages: The studies made by Seidman et al. sug-
analyzed 240 cases of EA with or without resection of gested that after TCRE the amenorrhea rate and the com-
polyps or fibroids for treatment of menorrhagia, with a plete relief rate of dysmenorrhea were significantly higher
mean follow-up of 31.2 months. Seventy-one percent in the older women than that in the young. In his postop-
didn’t have hysterectomy in the first 5 years, ten cases erative follow-up of 162 cases (95.9%) with the average
had another EA, of which six cases had the uterus duration 32 ± 17 months, it was found that postoperative
removed finally. After analysis of multiple factors, the complications were unrelated to age. There were no dif-
conclusion was reached that sterilization was a risk factor ference in ratio between a second hysteroscopic operation
for hysterectomy. The women of at least 45 years old had and hysterectomy. Cravello et al. reported 102 meno-
smaller risk for hysterectomy than those below 35 years pausal women aged 47–67 years with postmenopausal
old. In this report, the duration of the postoperative fol- bleeding or bleeding due to HRT. By hysteroscopy and
low-up of EA was longer than those in previous reports, ultrasonography, 87 cases were found to have benign
and a second EA and being young were risk factors for intrauterine lesions (51 cases of polyps, 36 cases of leio-
hysterectomy. Boe Engelsen followed up 390 procedures myoma), and 15 cases were found without significant
of TCRE in the following 4–10 years, and found that lesion; after endometrial ablation with polypectomy or
16.6% had hysterectomy for pain or bleeding; 50% of myomectomy, 88 patients (86.27%) were satisfied with
them were within 2 postoperative years, and 6 were found the long-term therapeutic effect. They concluded that the
to have malignant disease. He found that operation prog- therapeutic effect of TCRE depends on the causes of
nosis was unrelated to operator’s experience. In Munro’s hemorrhage rather than the patient’s age.
9.2.8.2 Endometrial Repair After TCRE/EA TCRE are as follows: (1) below 40 years old; (2) even with
Colgan et al. studied the process of endometrial repair after prolonged bleeding but a regular menstrual cycle; (3)
EA. Among 19 cases included, 15 cases were for DUB, and curettage with endometrial pathological results within 6

four cases were for endometrial hyperplasia which was dis- months; (4) uterus of normal size or slightly larger.
covered by TCRE. The uterus was removed 1–48 months During operation, the procedure begins with diagnostic
after operation for histological examination. Six specimens hysteroscopy. If any suspicion, samples are taken for exami-
were within 3 months post-operation, with myometrial nation and the procedure may proceed no further; otherwise,
necrosis, red foreign bodies, granulomatous response, ther-
mal damages, and changes of acute inflammation observed.
The remaining 13 specimens were obtained 3–16 months
post-operation, showing persistent granulomatous response
and/or foreign bodies. Most (9/12) had obvious endometrial
scar. So, it was thought that the postoperative reaction of EA
is granulomatous endometritis. In the Hysteroscopy Center
of Fuxing Hospital, Capital Medical University, 26 women
were observed hysteroscopically within 3 months to 1 year
following TCRE, who were found to have a small amount of
endometrium in uterine cavity regardless of menstruation
(Figs. 9.43, 9.44, and 9.45), but only those with no period
were found to have glandless endometrium.
9.2.8.3 One-Stage TCRE

TCRE usually takes three steps, namely, (1) hysteroscopy
and endometrial biopsy; (2) endometrial pretreatment for
inhibition of endometrial hyperplasia; (3) resection of endo-
metrium. In 1992, Van Damme tried not to apply endometrial
pretreatment with hormone drugs in some cases, but per-
formed (1) and (3) at one operation, thus simplifying the
TCRE procedures and reducing the patient’s pain, which is
one-stage TCRE. The selection conditions for one-stage Fig. 9.44 Endometrium and bleeding in uterine cavity after TCRE
Fig. 9.45 At 14 months after TCRE, the cavity is narrow with tiny
Fig. 9.43 Uterine cavity at 10 months after TCRE amount of endometrium in a woman with little menstruation
214 E. Xia et al.
dilate the cervix and go on with the operation. If endome- TCRE, she was treated with tamoxifen continuously and had
trium is thickening, perform curettage first to reduce its no bleeding in a follow-up of 2 years, and the result of ultra-
thickness, and send the endometrial samples for examina- sonography scanning showed no sonographic appearance of
tion. Then endometrial resection is performed with electric endometrium. Goldenberg et al. reported 11 cases of menor-
wire loop or endometrial ablation with rollerball electrode. rhagia due to blood coagulation disorders who were ineffec-
The current power of electric resection is 70 W and the cut- tive to medication. After TCRE, the satisfaction rate was
ting reaches 2–3 mm myometrium beneath endometrium, the high (10/11) in a postoperative follow-up of 1 year. These
resected muscle strips are also sent for histopathological patients cannot tolerate the major operations, so the hystero-
examination; the current power of electrocautery is 60 W and scopic operation is essential for them. Milad and Valle suc-
the depth is the site where the endometrial layer disappears, cessfully conducted emergency EA for 3 women with blood
and braided muscle fibers reveal. Xia conducted a prospec- coagulation disorders, which eased the sudden severe uterine
tive study of 125 cases of one-stage operation. Through a bleeding resulting from blood disease and reduced the
histopathological examination and follow-up, no cases of patients’ demand for blood products, but could not cure. The
endometrial cancer or premalignant lesions were found with use of rollerball electrode in EA is the most simple and safe
the operation satisfaction rate of 98%, and the success rate of method to treat severe uterine bleeding. The role of rollerball
99.2%. There were no differences compared with those who electrode is to close vessel and cause necrosis. Therefore, it
had the three procedures. It indicated that one stage of TCRE needs low power and high voltage. However, the resection of
was feasible, safe and effective, and consistent with Van endometrium or myometrial layer will open new blood ves-
Damme’s report of operation satisfaction of 97.5%. To per- sels and exacerbates bleeding. The uterine bleeding induced
form one-stage operation, one must pay high attention to two by leukemia or drugs can be reduced or stopped by EA.
steps: the preoperative selection of patients and intraopera- Romer reported 35 perimenopausal and menopausal
tive hysteroscopic diagnosis. Continuously improving and women, who underwent EA following hysteroscopy and
perfecting the ability to evaluate endometrial diseases under endometrial biopsy due to HRT induced bleeding with no
hysteroscope is the key to complete one-stage operation. complications, and continued to use the combined HRT after
Wortman and Daggett conducted a retrospective study of 304 operation. A follow-up of 12 months showed that 34 cases
cases of refractory uterine bleeding, with the average age 41 had amenorrhea and were satisfied with treatment; 1 woman
years and the mean duration of follow-up 32 months after stopped to use HRT for other side effects. It was believed that
operation. Eighty-three percent of the cases had no menstru- EA was a minimally invasive approach to treat this disorder
ation within 1 year, the total amenorrhea rate was 85.5%, and without intrauterine lesions, and after operation, HRT can be
only 0.8% showed no improvement. The histological exami- continued, thus increasing the compliance of HRT in the
nation showed that 17 cases (5.6%) had significant endome- selected cases.
trial lesions, which were not detected by routine preoperative
screening. Twenty cases (6.6%) had complications, of which 9.2.8.5 TCRE in the Treatment of Uterine
only two cases (0.7%) were severe. Twenty-seven cases Bleeding Caused by Severe Medical
required further operation. Finally, 69 patients (22.7%) were Diseases
found to have adenomyosis, which did not increase the rate Scholars in the Hysteroscopy Center of Fuxing Hospital,
of further operation. They concluded that the amenorrhea Capital Medical University, summarized the experiences of
rate after TCRE was very high, fewer cases required opera- 76 cases with medical diseases, and their operation informa-
tion due to complications, histological specimens might be tion can be seen in Table 9.2. In addition to regular TCRE
obtained, the rate of morbidity was lower, and the diagnosis preparation before operation, these 76 cases were also pre-
and treatment could be completed with one-stage operation. pared for other medical diseases. The cases with renal insuf-
ficiency were treated by hemodialysis, making BUN (blood
9.2.8.4 TCRE in the Treatment of Uterine urea nitrogen) under 80 mmol/L; the cases with blood dis-
Bleeding Resulting from the Hormone ease were pretreated according to its causes, with the anemia
Therapy and Blood Coagulation corrected and the deficiency of blood cell components sup-
Disorders plied, both the correction of anemia and supplement of plate-
Phillips’ data showed that 29 cases of uterine bleeding lets should be done for cases with leukemia; the cases with
induced by hormone replacement therapy (HRT) were unre- cirrhosis required the supplement of coagulation factors; the
sponsive to drug treatment, but continued with HRT after cases with diabetes should take oral hypoglycemic agents or
TCRE with the result of no recurrence of bleeding. Romer insulin injection to control the blood glucose level below
reported that a premenopausal woman with breast cancer had 11 mmol/L; the cases with cardiac valve replacement stopped
repeated uterine bleeding after taking tamoxifen and three the anticoagulant warfarin, the prothrombin time was moni-
curettages with no malignant lesion. After undergoing tored at the same time, and the operation could be done when
Table 9.2 Types of hysteroscopic operations of 76 cases with severe medical complications
Severe medical Renal Blood Heart Diabetes Cardiac valve Thoracic Lupus
diseases failure diseases disease mellitus Hypertension replacement deformity erythematosus Cirrhosis Total
No. of cases 22 18 11 10 9 3 1 1 1 76
TCRE 13 9 5 4 4 2 0 1 1 39
EA 0 5 1 0 0 0 0 0 0 6
TCRM 0 0 4 2 3 1 1 0 0 11
TCRE+P 7 4 0 4 1 0 0 0 0 16
TCRE+M 2 0 1 0 1 0 0 0 0 4
it was normal, and restored taking warfarin in 36–72 h after 9.2.8.6 Uterine Malignant Lesions Detected
operation. All 76 patients had successful operations with lit- During TCRE/EA
tle intraoperative bleeding, with the average depth of uterine In 2001, Vilos et al. reported three cases of uterine sarcoma
cavity 7.8 cm (6.5–8.2 cm), the average operation time which were detected in 2402 cases of TCRE. One of them
13.2 min (8–22 min), and the average weight of the removed was low-grade endometrial stromal sarcoma and the other
endometrial tissue 4.6 g (3–7 g). After operation, two cases two were carcinosarcoma. Two women underwent hysterec-
were complicated with severe anemia and transient fever, tomy and found no residual cancers in the specimen of
one case of cardiac mechanical valve replacement resumed uterus. The third woman was 82 years old and refused hys-
taking warfarin without permission 18 h later after TCRE, terectomy. She had moderate bleeding before surgery and
which resulted in active arterial bleeding of uterine cavity achieved amenorrhea after treatment. The author’s experi-
about 800 mL within 24 h post-operation and shock, then she ence was that the incidence rate of sarcoma of uterus was
was sent back to the operating room and bleeding stopped by about 1/800 of TCRE due to AUB, and that complete endo-
rollerball electrocoagulation of the bleeding point. Due to metrial resection may provide a diagnosis and a minimally
the decrease in platelet, the patient was transfused of two invasive treatment for patients at high risk for hysterectomy.
units platelet when she was back to the recovery room, and Agostini et al. assessed the risks of endometrial carcinoma
she recovered smoothly. In a follow-up of 6 months to 9 and atypical hyperplasia with postoperative histopathologi-
years and 6 months, two cases had irregular bleeding, who cal diagnosis on 325 postmenopausal women who received
were cured with the drug treatment. One case had amenor- hysteroscopic endometrial resection or ablation. All of cases
rhea, and because of the transplanted kidney failure, she died had postmenopausal bleeding or HRT related bleeding, and
of kidney failure after a year and half of operation; among performed diagnostic hysteroscopy with endometrial biopsy,
the rest 75 cases, 36 cases had amenorrhea, 28 cases had so that endometrial cancer or atypical hyperplasia was
dripping bleeding, and 11 cases had obviously reduced men- excluded. Then 203 cases underwent TCRE (62.5%) and 122
struation, with the operation satisfaction rate 96%. cases received EA (37.5%). Endometrial carcinoma and
Wallwiener et al. reported 34 cases of blood coagulation atypical endometrial hyperplasia were detected in two cases
disorders and refractory to medical treatment. In order to of each group. It was considered that diagnostic hysteros-
avoid hysterectomy, they underwent EA, with the postopera- copy with endometrial biopsy cannot fully exclude endome-
tive result of 64.71% amenorrhea or dripping menstruation. trial cancer or endometrial atypical hyperplasia, which may
And after a second EA, the amenorrhea or dripping men- be found during hysteroscopic operation.
strual rate increased to 82.35%, in which the effect of EA on
bleeding induced by the use of anticoagulants was obviously 9.2.8.7 TCRE for Emergency Hemostasis
superior to those with the endogenous blood coagulation dis- Franchini et al. underwent emergency TCRE for 25 cases of
orders. Therefore, it was considered that EA was a valuable severe uterine bleeding, of which one case was found to have
alternative in treating patients who had AUB associated with endometrial carcinoma and received hysterectomy instead,
coagulation and thrombosis disorders. Xia et al. reported 15 cases had amenorrhea after operation. Therefore, in a
1431 women who underwent TCRE in their Hysteroscopy follow-up of 19 months, it was found that TCRE could effec-
Center, of them 219 (15.30%) had severe medical complica- tively control uterine bleeding, prevent bleeding recurrence
tions. After operation, their life qualities were all improved and avoid drugs or operation treatment. Osuga et al. under-
in a short period, and in a long-term follow-up of 88 cases, went successful emergency EA for one postmenopausal
the satisfactory rate was 100%. It was concluded that TCRE woman with cirrhosis and morbid obesity who suffered from
was a good alternative to hysterectomy for AUB patients severe life-threatening uterine bleeding for invasive opera-
with severe medical complications. tion and had failed uterine artery embolization.
216 E. Xia et al.
9.2.8.8 Endometrial Adenocarcinoma Found the patients who had no period after operation. Therefore,
During TCRE they suggested that HRT should be used continuously in
Vilos et al. conducted a retrospective study of 13 women peri- or postmenopausal women including progesterone after
with abnormal bleeding who underwent TCRE and were endometrial resection or ablation. In 2000, Romer et al.
diagnosed as endometrial cancer by postoperative histopath- reported again that those who needed HRT after EA should
ological examination. All of them failed to take adequate be added gestagen. Continuous use of HRT could prevent
determinable biopsy during diagnostic hysteroscopy and postoperative bleeding, as well as prevent the residual endo-
endometrial biopsy before TCRE. Of them 8 women received metrium from hyperplasia. IUD containing progesterone can
total resection of endometrium (first group), 5 women be also used as a substitute after operation.
received partial resection (second group). By histopathologi-
cal examination of removed uterus after hysterectomy, two 9.2.8.11 TCRE for Infertility
cases in the first group had focal lesions, and no case in the Cravello et al. reported among the patients who underwent
second group had these lesions. There were no recurrences EA after ineffective treatment of AUB with progesterone,
0.5–9 years after hysterectomy. TCRE/EA are alternatives to there were some who had pregnancy after the cure of bleed-
hysterectomy in the treatment of DUB. If the existing endo- ing and might have a full-term labor.
metrial cancer is missed for diagnosis prior to EA, it will be
difficult to find after operation. In addition, the postoperative 9.2.8.12 TCRE for Adenomyosis
residual endometrium may also develop cancerization and its Xia et al. reported that among 208 patients who underwent
incidence is still unknown. Margolis et al. reported that a TCRE for AUB, 28 were found to have adenomyosis via
58-year-old woman who had undergone EA 3 years ago was intraoperative vision under hysteroscope, ultrasonography
incidentally found to have asymptomatic endometrial adeno- images of distension fluid penetrating into uterine myome-
carcinoma histopathologically after hysterectomy and trium, and report of histopathological examinations. After
Marshall–Marchetti–Krantz operation due to stress urinary follow-up of 3–34 months, 2 patients underwent hysterec-
incontinence. By histopathological examination of the speci- tomy, and the other 26 cases were satisfied with the operation,
men of the uterus, it showed invasion of the myometrial layer with the operative success rate 92.86%. All of cases achieved
>50%, FIGO stage IC. improvement of menstruations and cure of anemia. 77.8% of
18 patients with previous dysmenorrhea had elimination of
9.2.8.9 A Repeat TCRE/EA pain, of whom 22.2% achieved relief, with satisfactory out-
Wortman and Daggett assessed the safety and effectiveness of come in a short term. The improvement of menstruations is
a second hysteroscopic operation after the failure of EA and caused by failure of functional endometrial generation after
TCRE. Twenty-six patients with postoperative pain, bleeding, the removal of the basal layer of the endometrium. By analyz-
or asymptomatic hematometra following first endometrial sur- ing the causes of effective treatment for dysmenorrhea, they
gery underwent hysteroscopic endomyometrial resection with may have mild lesions with only junctional zone involved and
ultrasonography surveillance. The average time from the start thickened, and most lesions are resected or coagulated. The
of treatment to the repeated operation was 41.2 ± 47.9 months. ectopic endometrial foci are non-existent or reduced, leading
Five cases (19.2%) required a simple dilation of the uterus, 21 to decrease of spasmodic contractions of surrounding leio-
cases needed cutting the internal cervical os open before enter- myomas, resulting in relief or disappearance of postoperative
ing the uterine cavity. The average operation time was dysmenorrhea caused by stimulating ectopic endometrial
20.3 ± 9.5 min, the average weight of specimens was hematocele, edema, and bleeding. For patients who under-
6.7 ± 4.9 g. Fifteen (57.7%) specimens showed adenomyosis. went hysterectomy after operation, the lesions of adenomyo-
The mean follow-up was 23.2 ± 22.7 months; 23 cases (88.5%) sis had depth to serosa, which led to the failure of endometrial
were satisfied and hysterectomy was avoided. Three cases resection. Keckstein also believed that TCRE/EA could effec-
(11.5%) underwent hysterectomy due to postoperative pain or tively provide the treatment of the symptomatic superficial
bleeding. It was concluded that a second hysteroscopic opera- adenomyosis, and the hysteroscopic operation can cure the
tion is effective for those who failed in endometrial resection selected cases of symptomatic localized adenomyosis. In a
or ablation, with the result of amenorrhea or pain relief and study conducted by McCausland V and McCausland A, it was
helping the majority of patients to avoid hysterectomy. found that the outcome of endometrial ablation will be better
in cases with the depth of the penetration of adenomyosis into
9.2.8.10 Hormone Replacement Therapy After myometrium <2.5 mm, and be worse in cases with the depth
TCRE/EA of penetration >2.5 mm. In a retrospective study of success
Romer reported that more and more patients underwent rate in 121 cases with adenomyosis and underwent TCRE due
TCRE when their medication treatment was unresponsive to to failure of treatment of AUB with progesterone reported by
AUB. Residual endometrial foci could be found in 70% of Quemere et al., with a maximum duration of 8 years follow-
u p, it showed that the success rate following one operation tively. They used a questionnaire to measure the patients’
was 56%, and following one or two operations was 67%. 11% satisfaction, menstruation, health status, and quality of life 5
of the cases had repeat resections. 17 cases (19%) had hyster- years after treatment. The follow-up rate was 77% and the
ectomy due to the recurrence of bleeding. The result they results of the fifth year were: in medication group of 94
achieved was similar to those reported by others, and the patients, 7 were still using drugs; 72 finally underwent the
authors held that adenomyosis was not the failure factor of surgical treatment, including 17 patients of hysterectomy,
TCRE/EA, except there is deep adenomyosis difficult to be with satisfaction rate very low and unwillingness to intro-
diagnosed prior to operation. Zheng et al. from Hysteroscopy duce to friends. In TCRE group, 25 cases had a further oper-
Center of Fuxing Hospital, Capital Medical University, ation including 15 patients undergoing hysterectomy. The
applied TCRE in combination with LNG-IUS for treating scores of bleeding and pain were similar between two groups
adenomyosis in 20 women who wished to reserve the uterus and decreased significantly when compared with preopera-
and without the demand of fertility. A LNG-IUS was inserted tion. The health recovery in TCRE group was better than that
into the uterus following the procedure of TCRE. After 12 in medication group. It was thought that in the treatment of
months of follow-up, all women achieved amenorrhea, which severe menorrhagia, the use of TCRE might receive a high
indicated that the combined treatment could effectively avoid satisfaction rate, gain a reduced menstrual flow, improve
the prolonged dripping bleeding caused by the placement of greatly the patients’ health and quality of life, and be safe
LNG-IUS alone, and prevent the occurrence of the complica- without additional hysterectomy. Thus it could be introduced
tions including postoperative pregnancy, uterine hematocele, to the patients who meet the requirements. Mansour reported
recurrence of bleeding and expulsion of IUD, etc. Furthermore, that since the development of mirena (levonorgestrel, LNG-
Dr. Xia held that endometrial resection with the combination IUS), 9 millions of women from the whole world had already
of laparoscopic uterine artery blockage, or repeat coagulation used it for contraception and menorrhagia treatment. For
of cutting surface with vaporizing electrode following resect- women of childbearing age, LNG-IUS is one of the most
ing could improve the operative outcomes. acceptable drug therapies. Istre and Trolle held that both
LNG-IUS and EA have the same therapeutic effects of treat-
9.2.8.13 TCRE Applied to Larger Uterus ing menorrhagia, but LNG-IUS can be reversible and with
In a retrospective analysis conducted by Eskandar et al., of little operative risk. In 2010, de Souza et al. conducted a ran-
42 cases of uterine bleeding, with the uterine volume >12 domized prospective study of the application of LNG-IUS or
weeks, the length of uterine cavity >12 cm, and the average thermal balloon ablation for menorrhagia, and found that the
age 45.6 ± 6 years, a comparison was made in the application volume of blood loss in both groups was significantly
of TCRE and EA of its practicability, safety, prognosis, and decreased, but no statistic difference was detected between
irrigation fluid absorption. Twenty-six patients (62%) had two groups. In another randomized control trial recently
endometrial pretreatment, 27 patients (65%) underwent EA reported by Gupta et al., it was found that, when compared
surgery, and 27 patients (65%) had TCRE, all of which were with conventional medical treatment, the proportion of the
done in a day surgery setting. They used multiple regression cases changing to other treatment or terminating the treat-
analysis to explore the correlation between the size of uterus, ment in the group of using the LNG-IUS within 2 years was
pretreatment, procedures, operation time, and irrigation fluid lower, and the satisfactory score achieved in cases using
absorption, with the result that there was more absorption of LNG-IUS for menorrhagia was higher. Gupta et al. also
irrigation fluid in TCRE than that in EA (P = 0.04), and that compared the effectiveness of LNG-IUS with TCRE in
the absorption volume was related to the type of operation patients with DUB. One year after the treatment, the decrease
(R = 0.32, P = 0.04), but unrelated with the operation time, of the period volume and the rise of hemoglobin levels in
the size of the uterus, and pretreatment. Two women under- LNG-IUS group were nearly the same as those in TCRE
went hysterectomy because of uterine fibroids or endome- group, which indicated that treatment with LNG-IUS had
trial cancer. In 39 cases with a follow-up of 12–16 months, similar effects to surgical treatment in reducing the bleeding
amenorrhea was achieved in 30, oligomenorrhea achieved in and improving anemia. In addition, placement of LNG-IUS
6, and normal menses in 3, with the satisfaction rate of 93% required less experience and could provide contraceptive
(38/39). They held that EA was still a feasible, safe and effects.
effective alternative to hysterectomy for treatment of menor-
rhagia even though the uterus is large. 9.2.8.15 Comparison Between TCRE
and Transabdominal or Transvaginal
9.2.8.14 Comparison of TCRE and Drug Therapy Hysterectomy
for the Treatment of Menorrhagia From the worldwide literatures reported in cases with TCRE,
Cooper et al. conducted a follow-up of 187 patients with 70–90% of the subjects were satisfied with the outcome of
menorrhagia treated by TCRE or medical treatment, respec- treatment, of which 40–60% had amenorrhea after operation,
218 E. Xia et al.
30–50% had oligomenorrhea, and 10–15% had normal men- women who were readmitted for gynecological reasons, the
struation, with a failure rate of 5–12%. It has been found that readmission rates were similar in both groups within postop-
hysteroscopic surgery has the advantages of shorter opera- erative 6 months and were lower in hysterectomy group than
tive time, less complications, less requirement for analge- that in TCRE group. Therefore it indicated that, within 5
sics, quicker postoperative recovery, and sooner return to years after hysterectomy or TCRE, the readmission rate in
work compared to hysterectomy. The cost of TCRE abroad is hysterectomy group was lower, especially for those readmit-
much lower than that of hysterectomy, while they are similar ted for gynecological reasons. They concluded that hysterec-
in China. Alexander et al. conducted an important random- tomy appeared to have more definitive effect. The data
ized comparative study of the mental factors in cases after presented by Hidlebaugh showed that the cost of transvagi-
hysterectomy and resection of endometrium. The results nal hysterectomy was the least. Compared with abdominal
showed there was a reduction in the mental symptoms fol- hysterectomy, the direct cost of laparoscopic-assisted vagi-
lowing operation in both groups and no differences in sexual nal hysterectomy was higher, while the indirect cost was sig-
life and marriage relationship between the two groups. nificantly low. Both direct and indirect costs of TCRE/EA
However, the operator of hysteroscopic procedure requires were significantly lower than those of hysterectomy, even
special training and operative experience; and non-isotonic including the cost of treatment failures. TCRE/EA avoided
irrigation fluid and any dangerous energy source can cause major surgery, shortened hospitalization period, rapidly
complications, while the operator who performs abdominal returned to normal activity, and should be the preferred
or vaginal hysterectomy has no such worries. For patients method for patients with AUB.
who should undergo hysterectomy due to menorrhagia,
Pinion et al. performed hysterectomy in 99 cases and hys- 9.2.8.16 Comparison Between TCRE and Other
teroscopic surgery in 105 cases, of whom TCRE in 52 cases Methods of Endometrial Ablation
and HEAL in 53 cases. The outcomes observed included As an alternative to hysterectomy in the treatment of abnormal
complications, postoperative recovery and menstruation, uterine bleeding caused by benign lesions, endometrial abla-
relief of other symptoms, and patients’ satisfaction in the two tion is to use various energy sources or technical design to
groups. Compared with women who had hysterectomy, reduce menstrual blood loss. The rollerball electrocoagulation
women undergoing hysteroscopic surgery had less morbidity endometrial ablation and the laser endometrial ablation are
in early term postoperatively and had shorter recovery two of these minimally invasive techniques, which have the
period, with the full recovery period 2–4 weeks, and 2–3 similar therapeutic effects to TCRE. Recently, there are a
months in women with hysterectomy (P < 0.001). With the number of new minimally invasive non-hysteroscopic tech-
follow-up of 12 months after hysteroscopic surgery, postop- niques available in the treatment of menorrhagia, including
erative outcomes included hysterectomy (17 cases), repeated radiofrequency endometrial ablation, microwave endometrial
hysteroscopic surgery (11 cases), menorrhagia or brown dis- ablation, bipolar electroresection, uterine balloon thermo-
charge (45 cases), and light period (35 cases). Most cases in ablation, cryo-endometrial ablation, photodynamic endome-
both groups had a relief in dysmenorrhea or premenstrual trial ablation, laser beam (laser thermal ablation), hydro
symptoms. At 12 months after operations, the satisfaction thermo-ablation, and so on. Vilos et al. reported an endome-
rates were 89% (79/89) and 78% (85/89) respectively in hys- trial ablation system with uterine thermal balloon for the treat-
terectomy group and hysteroscopy group (P < 0.05), the ment of menorrhagia, and the initial results in a postoperative
relief of the symptoms were 95% (85/89) and 90% (86/96) 18-month follow-up indicated that the postoperative improve-
respectively, and the expectation of the patients to recom- ment in menorrhagia was 77%, which was similar to other
mend their surgery to others were 72% (64/89) and 71% techniques of endometrial ablation. However, with the passage
(68/96) respectively. They concluded that hysteroscopic sur- of time, the failure rate might be increased, and another endo-
gery had less complications and shorter recovery time than metrial surgery was needed. Since this is a simple operation
hysterectomy. Though hysterectomy achieved a higher satis- and just involves the techniques as placement of IUD into the
factory rate, it was between 70 and 90% with hysteroscopic uterine cavity, the chances of severe complications are slim,
surgery. Hence they insisted that hysteroscopic surgery could and thus, it is generally considered as the primary method of
be considered as an alternative to hysterectomy for treatment treatment for menorrhagia. Nisolle insisted that this non-hys-
of DUB. Clarke et al. investigated the readmissions of teroscopic EA is only suitable for DUB, and the endometrial
patients within 5 years after TCRE or hysteroscopy, to deter- biopsy should be done before operation. If biopsy reveals nor-
mine whether TCRE can replace hysterectomy. The results mal endometrium and ultrasonography shows no polyps or
showed that within 5 years following surgery, the readmis- fibroids, then it is feasible to administer non-hysteroscopic EA
sion rates were 41.7% in women with hysterectomy and in the treatment of DUB. In 2007, Deb et al. from the United
44.6% in women with TCRE. Readmissions for gynecologi- Kingdom collected the data from 610 doctors, of whom 449
cal reasons were 12.6% and 30.3%, respectively. Among (73%) performed TCRE or EA. The most preferred method
was thermal balloon ablation (32.1%), then microwave endo- labor. This is not only common in women of 40–50 years
metrial ablation (29.8%). The orders of other techniques were old, but also in young women, and severe bleeding and infer-
TCRE alone or combined with roller ball coagulation (18.5%), tility may be caused. Under normal circumstances, the size
Novasure (9.8%), hydrotherm ablation (6.9%), rollerball abla- of uterine myoma decreases in postmenopausal women.
tion (2%), and laser ablation (0.9%). There were 52.2% of Submucous myoma is often complicated by chronic endo-
patients applying GnRH analogs as pretreatment medication. metritis, and is at a higher risk of malignancy (leiomyosar-
Variations in treatment methods have made a challenge of coma) and bleeding tendency. Since the submucous myoma
assessment of clinical efficacy. Wamsteker held that the great- cannot be felt by pelvic examination, and cannot be detected
est advantage of EA/TCRE under hysteroscope was in com- by blind sounding of uterine cavity, only when severe uterine
pleting the treatment under direct vision of uterine cavity from bleeding leads to anemia can it sometimes be found. The
the beginning to the end of operations, while the problems commonly used methods in examining uterine myomas
with the other non-hysteroscopic treatments are lack of visual- include HSG, MRI, ultrasonography (especially transvaginal
ization or control of the procedures. He pointed out that ultrasonography), and hysteroscopy under direct vison of
although the above non-hysteroscopic EA operations were uterine cavity, etc. The blind dilation and curettage (D&C)
often advertised as “day surgery,” they were not found suitable may not detect submucosal myomas, and ultrasonography is
for outpatient, at least for now. In addition, the disposable not accurate in positioning. Thus hysteroscopy is the pre-
equipment was expensive, and it was useless to operators who ferred method in the diagnosis of this disorder. In 1976,
were experienced with EA or TCRE. Up to now, a number of Neuwirth and Amin first reported the application of prostatic
studies indicate that the techniques using these devices can resectoscope in performing transcervical resection of myoma
produce the same therapeutic effects as the traditional hystero- (TCRM; hysteroscopic myomectomy). Thereafter, with the
scopic resection or ablation, but more studies will help to progress of equipment and technology, operative hystero-
account for the appropriate role of non-hysteroscopic devices scope came out in 1992, which is exclusively applied in
for EA in gynecology. In view of the risk and complications of gynecologic surgeries. By now, hysteroscopic resection of
hysteroscopic operation, great care should be taken to prevent submucosal myomas and inward-protruding intramural
the most severe hyponatremia encephalopathy and fluid myomas has developed into mature techniques in gyneco-
overload. logic surgery. Compared with hysterectomy and transab-
It is worth mentioning that recently a large number of ret- dominal myomectomy, hysteroscopic resection of
rospective studies were carried out to compare the results of submucosal myomas has many advantages. Firstly, it does
transurethral resection of the prostate (TURP) and open not need to open up the abdomen, which significantly reduces
prostatectomy, which indicated that there were only a few postoperative recovery time, and small myomas can be
cases dying of cardiovascular disease after operation of resected at outpatient department. Secondly, there is no sur-
TURP in an 8-year follow-up of patients, but it was signifi- gical incision into the uterus, which greatly reduces the sub-
cantly more than that of patients after open prostatectomy. sequent possibilities of cesarean section. Finally, its
TCRE is similar to TURP in many aspects, but is completely prognosis can be comparable with traditional laparotomy.
different from TURP in diseased population and operation
procedures. Therefore, these findings do not apply to the
hysteroscopic operation. However, the research suggests that 9.3.1 Classification of Uterine Myomas
short-term experience cannot foresee long-term effects, and
a proper follow-up is needed when the safety and efficacy of Uterine myomas originate from smooth muscle cells, and usu-
this new technology are evaluated. ally migrate to the site with little resistance in the growing
process. If migrating towards the abdominal cavity, it will
grow beneath the serosa. If migrating towards the uterine cav-
9.3 Transcervical Resection of Myoma ity, it will grow beneath the mucosa. According to its location,
uterine myomas are divided into three types: (1) submucous
Enlan Xia and Ning Ma myomas: located beneath the endometrium; (2) intramural
myomas: located within the myometrial layer; (3) subserous
Uterine myoma, also named uterine leiomyoma, is the myomas: located directly beneath the serosa. Most of myomas
most common solid tumor, and also the most common indi- in uterine cavity grow partly in the uterine wall, and partly
cation for hysterectomy. It was estimated that 20–25% of beneath the endometrium and protrude inwardly, which are
women over 35 were suffering from this disease. Its symp- named sessile submucosal myomas, and myomas with pedi-
toms include menorrhagia and abnormal uterine bleeding, cles are named pedunculated submucosal myomas. The diam-
which may lead to anemia, dysmenorrhea and (or) lower eter of myoma can be less than 1 cm, or more than 8–9 cm, can
abdominal pain, lumbosacral pain, infertility, and premature be single or multiple. There is always no normal endometrium
220 E. Xia et al.
on the surface of submucous myomas, only covered with a cous myomas being excised; (2) the embedded submucous
thin and dense capsule. On its surface, the thick blood vessels myomas: under irrigating fluid pressure, the sessile sub-
can be seen easily under hysteroscope. Once the blood vessels mucous myoma may sometimes be embedded into the
rupture, the blood may spurt from blood vessels and fill up the myometrial layer and turned into intramural myoma.
uterine cavity rapidly due to the lack of self-limiting mecha-
nism of hemostasis. Most submucous myomas are located at Uterine myomas may possibly undergo sarcomatous
the corpus of the uterine cavity, attached to the fundus, the change, but extremely rare, with its incidence <0.5%.
anterior, posterior or lateral uterine wall. Small myomas may Therefore, the resected tissues of myoma must be sent for
be located at the uterine cornua, which may interfere with the histopathological examination.
normal junction of uterus and fallopian tubes. Very few myo-
mas are located at the cervical canal.
According to the relationship between myomas and the 9.3.2 Indications and Contraindications
myometrium, Haarlem international hysteroscopy training of TCRM
center in the Netherlands classifies the submucous myomas
into three types (Fig. 9.46), which has been widely adopted Any patients with submucous myoma, inward-protruding
internationally. Type 0 (Fig. 9.47a–d) is pedunculated sub- intramural myomas, and cervical myoma should first con-
mucous myomas without intramural extension. Type I sider hysteroscopic operation, although the hysteroscopic
(Fig. 9.48a–c) is sessile submucous myomas with intramural surgeries are not applicable to all myomas. In order to have a
extension <50%. Type II (Fig. 9.49a, b) is sessile submucous safe operation and good therapeutic effect, one key point is
myomas with intramural extension >50%. Type I can be dis- to select the patients suitable for the operation. The operator
tinguished from Type II under hysteroscope in that the endo- must formulate the suitable conditions according to his own
metrium migrates from the uterine wall at an acute angle experience and surgical techniques, and an improper opera-
towards the type I myoma while at an obtuse angle towards tion will lead to dangerous consequences. The size of the
the type II myoma (Fig. 9.50). myoma is generally limited to below 5 cm in diameter, and if
According to the relationship between the myomas and skilled, the operator may extend its indications. Sometimes,
myometrium, and in combination with the operative meth- the operations on the submucous myoma which is embedded
ods, Lin makes a classification of myomas as follows. deep into the myometrium and inward-protruding intramural
myomas need to be performed more than twice. Intramural
1. Pedunculated submucous myomas: (1) prolapsed myo- myomas which don’t deform the uterine cavity and subsero-
mas; (2) myomas without prolapse. sal myomas are unsuitable for hysteroscopic operation.
2. Sessile submucous myomas: (1) 50% ≥ the degree of The following conditions should be considered in select-
protrusion ≥20%; (2) the degree of protrusion <20%. ing indications:
3. Intramural myomas close to the uterine cavity: (1) intra-
mural myomas protrude into uterine cavity after submu- 1. Menorrhagia or abnormal bleeding.
2. The size of the uterus and the length of the cavity: The
size of the uterus is generally confined to 10 weeks of
gestation and the uterine cavity is limited to 12 cm in
length.
3. The diameter of submucosal or inward-protruding intra-
mural myoma: It is generally restricted to less than 5 cm.
4. The size of a pedunculated submucous myoma: It is gen-
erally restricted to less than 5 cm.
5. No cancerous change.
As to the submucosal myoma that has prolapsed into the

vagina, its size and the thickness of its pedicle are not
restricted.
Its contraindications are similar to that of TCRE.
9.3.3 Preoperative Preparations
9.3.3.1 Case Selection

Before deciding on hysteroscopic operation, a general preop-
Fig. 9.46 Submucous myoma erative examination must be undertaken to determine the
a b
c d
Fig. 9.47 (a–d) Type 0 pedunculated submucous myoma
presence of submucous myoma and (or) inward-protruding 2. HSG: HSG shows intrauterine filling defects, but often
intramural myomas. The number, size, location, and degen- misses the small myomas, and may confuse large polyps
eration or not of myomas are recorded, thus the possibility of and bubbles. Its advantages are that it can help to evaluate
hysteroscopic operation is assessed. The common methods the fallopian tube patency, and also diagnose adenomy-
for evaluating myomas are as follows: oma with images revealing the multiple channels within
myomas being connected with uterine cavity.
1. D&C: The uterine cavity may be examined by a sound or 3. Ultrasonography: Ultrasonography is used to measure the
explored by a curette, if found uneven, it suggests the radial lines of the uterus and submucous myoma with
possibility of submucosal myoma. Its advantage is that it abdominal or vaginal probe. However, myomas may be
can take endometrium for histological examination at the misdiagnosed with endometrial polyps or thickened
same time, but it has a higher false negative rate. endometrium, and it is also not easy to locate myomas.
222 E. Xia et al.
a b
Fig. 9.48 (a–c) Type I sessile submucous myoma
Hysteroscopic examination combined with ultrasonogra- biopsy under direct vision should be done for histologi-
phy or saline infusion sonogram (SIS) is convenient for cal examination to exclude malignant lesions. The defor-
observation and classification of uterine submucous mation or irregularity of the uterine cavity, and
myoma (Fig. 9.51). asymmetry of bilateral uterine cornua and tubal ostia can
4. Hysteroscopy: Hysteroscopy can be used to observe be detected in the inward-protruding intramural myoma.
directly the shape, color, and location of submucous However, the hysteroscopy alone cannot help to under-
myomas, thickness of pedicles, single or multiple, the stand the depth of myomas into uterine wall, the size of
conditions of the endometrium on their surfaces, and myomas, and whether the locations of tubal ostia are
their degree protruding into the uterine cavity, so that a involved when the myoma extends to the fallopian tubal
decision might be made as to whether it is suitable for ostia.
hysteroscopic operation or not. When necessary, in vivo
a b
Fig. 9.49 (a, b) Type II sessile submucous myoma
50%
75%
25%
100%
0 Uterine Cavity
Fig. 9.50 The degree of submucous myomas protruding into the uter-
ine cavity
Fig. 9.51 Image of submucous myoma under SIS
5. MRI: MRI can clearly show the soft tissue image and can
assess the size of uterine myomas quantitatively. myomas, the effects of GnRH analogs were more obvious
than that of other hormones. GnRH analogs can cause the
9.3.3.2 Preoperative Medical Pretreatment endometrium and uterine vessels to atrophy, making a wide
Prior to operation, the patient can be administered danazol, field of vision and less amount of bleeding during operation
600–800 mg/day, or gestrinone/nemestran 2.5 mg, twice (Fig. 9.52a, b), while the myoma is fragile and is easy to be
weekly, for more than 3 weeks, or GnRH analogs for 10–12 clamped out with forceps. Generally, the application of
weeks, which can reduce the volume of myoma and decrease GnRH analogs may lead to amenorrhea and improve the ane-
blood supply. The uterus shrinks faster than myomas, thus it mia, but one should remember that it must be administered at
is very beneficial for the myomas to protrude into the uterine the early stage of the menstrual cycle. After taking it for the
cavity, be transformed from the sessile submucous myoma first time, very few patients will have an increased menstrual
into pedunculated one, and increase the degree of protrusion flow and sometimes need to terminate the administration of
of intramural myoma into uterine cavity, which facilitates the GnRH analogs. There have been reports of drug-induced
smooth hysteroscopic operation. Donnez et al. suggested heavy bleeding and emergency rescue required in cases of
that in reducing the volume of the uterus and submucosal excessive bleeding.
224 E. Xia et al.
a b
Fig. 9.52 (a) The endometrium becomes thin after 2-month application of GnRH analogs. (b) The endometrium becomes significantly thin with
blood vessels unclear after 3-month application of GnRH analogs
9.3.3.3 Routine Laboratory Examination amount of tissues to be resected, a 9 mm hystero-

Routine laboratory examination includes blood coagulation, resectoscope can be used. An 8 mm hystero-resectoscope
electrolytes, liver function, blood type, etc. These results has the advantages of both 7 and 9 mm resectoscopes.
may help to establish a credible base before the operation 2. Lin’s myoma forceps: If large submucous myomas are
produces false experimental results, and can be used to make resected with hystero-resectoscope alone, there will be a
a comparison with all kinds of parameters when fluid over- limited amount of tissue resected with wire loop elec-
load is suspected during operation. trode each time, the operation will take a longer time, and
the bleeding volume will increase, which may increase
9.3.3.4 Timing of Surgery the risk for hyponatremia. Lin’s myoma forceps has a
The ideal time for operation is in the first half of menstrual wider clamping blade, and its inner surface appears to be
cycle, during which there may be less bleeding at the time of cross-shaped, hence it can hold and pull out the residual
operation. If there is excessive bleeding, the operation must myoma tissues more firmly compared with the oval for-
be done even in the secretary phase. If the myoma does not ceps, and also effectively shorten the operative time.
prolapse out of the cervical canal, an osmotic dilator or a 3. High-frequency current generator: The electric cutting
laminaria tent can be inserted into the cervical canal on the power is set at 80 W, electric coagulating power is set at
night before operation. 40 W, and both can be increased according to the require-
ments of operation. The blended current with cutting and
coagulating is mainly used when resecting tissues.
9.3.4 Anesthesia However, the pure electric cutting current may be applied
to achieve smooth resection.
The choices of anesthesia can be seen in section of TCRE. All 4. Irrigation fluid: Since submucous or inward-protruding
kinds of anesthesia may be administered except for local intramural myomas occupy the partial uterine cavity, if
anesthesia, and general anesthesia should be adopted when there are more debris of the resected myomas, and if the
laparoscopy is performed at the same time. irrigation fluid cannot distend the uterine cavity ade-
quately during operation, there will be a narrow operative
space and poor vision. These may lead to difficulty in cut-
9.3.5 Operative Equipment ting myomas, damage to the opposite uterine wall, and
even perforation of the uterus. When there is poor irriga-
1. Hystero-resectoscope: A 7 mm hystero-resectoscope with tion achieved by using the falling pressure of distention
continuous irrigation can be used to cut the thin pedicle of fluid and outflow negative suction, an automatic uterine
a submucous myoma, or transform sessile submucous distension pump is needed to distend the uterine cavity
myoma into the pedunculated one. When there is a large mandatorily with a continuous flow.
9.3.6 Operative Procedures
First, examine the location of myoma and the condition of

pedicles carefully by ultrasonography. Then, perform opera-
tions according to the types of the myomas.
9.3.6.1 Pedunculated Submucous Myomas

1. Prolapsed myomas: The main body of a myoma is located
in the cervical canal or in the vagina, but the root of ped-
icles still remains in the uterine cavity or within the cervi-
cal canal, which is the best object of hysteroscopic
operation for beginners. During the procedure, the
myoma is grasped and pulled outwards first by double
hook forceps, rather than being grasped and screwed out
roughly. Meanwhile, insert a 7 mm hystero-resectoscope
into the uterine cavity to cut off its pedicle. When cutting,
in case of difficult positioning of pedicle, move the dou-
ble hook forceps so the pedicle can be mobile, which
makes it distinguishable from the normal tissues.
Moreover, as a result of pulling, the normal tissues under-
lying the pedicle will protrude into the uterine cavity. Fig. 9.53 Prior to TCRM
When hystero-resectoscope is applied to cut off the pedi-
cle, the cutting should be taken at a direction parallel to
the normal uterine wall, since the cutting may damage the
normal myometrium if it takes the direction of the uterine
wall. After removal of myoma, its cutting surface will
retract, and an additional resection is not needed
generally.
2. Myomas without prolapse: From the external orifice of
the cervix, the operator cannot see the site where the
pedicle is attached and that the main body of myoma
still remains in the uterine cavity or cervical canal. By
Lin’s method of resection, first use a 7 mm resecto-
scope to cut the pedicle of myoma into one less than
1 cm, and then use a 9 mm resectoscope to shave the
tumor, thus reducing its size, and then screw it out with
Lin’s myoma forceps (Figs. 9.53, 9.54, 9.55, and 9.56).
This is two resectoscopes method, which is very
useful.
9.3.6.2 Sessile Submucosal Myoma

The resection of sessile submucous myomas needs highly
proficient skills. The operator must first grasp the techniques
Fig. 9.54 Resection of the right upper portion of a uterine myoma with
of resection of pedunculated myomas before performing electric cutting loop
such more difficult surgeries. The site of myoma is in the
uterine cavity or cervical canal. If it is sessile submucosal
myoma in the cervical canal, since the cervical wall has 1. 50% ≥ the degree of protrusion ≥20%: To remove such
become very thin, it is extremely prone to perforation, and a myoma completely, first of all, one must strive to
the operation is the most difficult. There are two kinds of increase the protruding degree of the submucosal
operating methods according to the protruding degrees of myoma. Under intensive monitoring of ultrasonogra-
myomas towards the uterine cavity. phy, a 7 mm wire loop electrode is used to cut gradually
226 E. Xia et al.
Fig. 9.55 Resection of the left lower portion of a uterine myoma with Fig. 9.57 Inward-protruding intramural myoma
electric cutting loop
the hysteroscope forms hydro-dissection, which

strengthen the dissection effects. The uterine muscle
contraction due to the high-frequency electric stimula-
tion and the resectoscopic insertion and extraction may
result in a change of pressure in uterine cavity, which
further prompts the myoma to protrude into the uterine
cavity. When the resection has been undertaken to a cer-
tain stage, clamp myomas with myoma forceps, twist
and pull under ultrasonography monitoring, which may
then develop a pedicle. When a pedicle is formed, the
resection is then similar to resection of a pedunculated
submucous myoma mentioned above. If it is not possi-
ble to screw and twist with forceps, insert a 7 mm resec-
toscope again to resect the pedicle of myomas, or use a
9 mm resectoscope to make the myoma core smaller.
Then use the myoma forceps to screw and twist the
myoma or twist the clamped myoma by 360°, pull it out
of the uterus and cut it off. However, if the myoma ped-
icle is too thick and the myoma is seized hastily and
pulled roughly, sometimes it will damage the uterine
wall and even directly to the serosal layer, resulting in
Fig. 9.56 A myoma was resected with incisions from above and below
with electric cutting loop so as to be easily clamped out
perforation of the uterus. If a laminaria cervical dilator
can be inserted to soften the cervix prior to operation,
small myoma core may be extracted with myoma for-
along the capsule at the bottom of the myoma. Just like ceps (Figs. 9.57, 9.58, 9.59, 9.60, 9.61, and 9.62).
abdominal myomectomy, the boundary layer between 2. The degree of protrusion <20%: It is difficult to have a
myoma and myometrium is cut open, and the myoma is complete resection, thus the operator should consider this
dissected bluntly from the muscular layer while using sessile submucosal myoma as intramural myoma for
the front tip of the hysteroscope to press myomas. At treatment. In fact, when resection starts, the myoma
this moment, the irrigating fluid flowing from the tip of begins to protrude into the uterine cavity, thus a complete
Fig. 9.58 The basal part of myoma Fig. 9.60 Uterine cavity after TCRM
Fig. 9.59 Electric resection of myoma Fig. 9.61 Uterine cavity before TCRM
resection is not uncommon. If it cannot be completely 9.3.6.3 Intramural Myomas with Inward
removed, a 9 mm resectoscope can be used to resect the Protrusion or Close to the Uterine Cavity,
portion of myoma protruding into the uterine cavity and and Transmural Myomas
the intramural part of myoma with the cutting depth more 1. Intramural myomas protruding into the uterine cavity:
than 5 mm. At 2–3 months after operation, a second-look Hysteroscopy is available for resection of this type of
hysteroscopy is conducted, and then TCRM can be per- myomas. Myometrial tissues between the myoma and the
formed again to resect the residual myoma completely endometrium can be seen on the cutting surface. The sur-
which has protruded into the uterine cavity, namely, the gical procedure is in accordance with that of submucous
two-step operation . myomas with the protrusion <20% described above.
228 E. Xia et al.
Fig. 9.62 Uterine cavity after TCRM Fig. 9.63 Multiple uterine submucous myoma
2. After resection of submucous myoma, some intramural

myomas may protrude into the cavity, then they can be
resected according to the procedures of sessile submu-
cous myoma removals.
3. Transmural myoma: It refers to the myoma throughout
the full layer of muscle wall, which is compressing on the
uterine cavity and protruding to the serosa, and the surgi-
cal procedure can be in accordance with sessile submuco-
sal myoma.
4. Embedded submucous myoma: It is caused by pretreat-
ment with GnRH analogs in sessile submucosal myoma,
with its normal myometrial tissues becoming brittle and
soft. Its resection is very difficult, while there are also
successful cases of complete resection under close ultra-
sonography monitoring.
9.3.6.4 Multiple Submucous and Intramural

Myoma
To the women who are suffering from multiple submucous
and intramural myomas with infertility, hysteroscopic myo-
mectomy can be applied. The techniques of resection and Fig. 9.64 Resection of multiple myomas with wire loop electrode
vaporization are the same as mentioned above, and myomas
should be resected as much as possible. When the operation
ends, IUD can be placed in the uterine cavity, and taken out embedded in the cervical walls, as long as its outline is made
2 months later (Figs. 9.63, 9.64, 9.65, and 9.66). clear, the wire loop electrode can be used to cut from the
thinnest part of the embedded myoma. When cutting reaches
9.3.6.5 Cervical Myoma the myoma, the incision can be appropriately extended and
Cervical myomas are all coated. For the cervical myoma pro- the myoma can be stripped out from the pseudo-capsules
lapsed from the cervical canal, wire loop electrode can be completely. After removal of the myoma, generally its bed
used to cut off the pedicle and remove it completely, or cut does not bleed. If the bed is larger or the outline of cervix is
open the pseudo-capsule and screw it out. As for the myoma not integrated, the absorbable catgut can be used for suture.
rollerball electrode or Nd-YAG laser. However, there is no

report about the comparison on therapeutic effects of two
methods.
9.3.6.7 Removal of Adenomyoma

In rare cases, an inward-protruding intramural myoma or a
sessile submucous myoma diagnosed clinically or by ultra-
sonography is really adenomyoma. There are three types of
adenomyomas. In type one, the agglomerate structure con-
sists of all adenomyoma tissues, with no clear capsule. And
on its section, the clustery endometrium, old blood, and
abundant blood vessels are visible. During the resection, the
adenomyoma may be deformed along with the contraction of
uterus. Therefore, do not overdo it at the time of resection,
and remember not to pursue a complete resection of adeno-
myoma so as to avoid cutting through the uterine wall when
the adenomyoma is deformed. Type II is adenomyoma com-
plicated with leiomyoma. Type III is a mixed type of tumor,
which is mainly leiomyoma, and at the portion of it close to
the cavity, the endometrium invades in and the partial adeno-
Fig. 9.65 Resection of multiple myomas with wire loop electrode myoma is developed. The second and third types of adeno-
myomas generally have obvious capsules, and the resection
methods are the same as that of the inward-protruding intra-
mural myoma and (or) sessile submucosal myomas.
9.3.6.8 Large Myomas >6 cm in Diameter

Some scholars have conducted special expositions on hys-
teroscopic resection of large myomas. Lin from Japan used a
7 mm resectoscope to cut the basal part of the myoma, trans-
forming the sessile myoma into the pedunculated one. Then,
a 9 mm resectoscope was used to resect the myoma. After the
reduction of its size, myoma forceps were used to clamp it
out, which greatly reduced the difficulty of operation. Loffer
reported 43 women who had large myomas and were given 2
months of danazol or leuprolide before operation. During the
operation, the myoma was resected to the level of the sur-
rounding endometrium and the intramural portion of myoma
remained inside myometrium. After the myoma fragments in
the uterine cavity were cleared out at the end of the resection,
the uterus might contract again and the myoma remaining in
the myometrium would protrude into the uterine cavity. At
this time, the resection should be proceeded immediately so
Fig. 9.66 Resection of multiple myomas with wire loop electrode as to avoid the prolapse of myoma, and there were no serious
operative complications. Donnez et al. reported 60 cases of
For sessile submucous myoma in cervical canal, it is laser myomectomy pretreated with GnRH analogs, of which
extremely prone to perforation since the cervical wall has the largest resected myoma was about 4 cm in diameter. His
become very thin. method was to remove myomas as much as possible, destroy
the blood supply of the residual myoma by laser, and con-
9.3.6.6 Simultaneous Resection of Endometrium tinue to apply GnRH analogs for 8 weeks after operation.
and Myoma The residual myoma was resected when moving into uterine
For the women who has severe bleeding and do not require cavity. Two to three months after treatment, the myomas
fertility, the operator may consider the simultaneous resec- were not notable and all the patients had normal menstrua-
tion of endometrium and myoma, which can be done with tion. Among 24 women who desired to have babies, 16
230 E. Xia et al.
(67%) conceived and had full-term delivery of live births ing the whole myometrium, most of which are smaller than
(Figs. 9.67, 9.68, 9.69, 9.70, 9.71, 9.72, and 9.73). 3 cm. Women with DUL usually manifest menorrhagia and
infertility. The uterus can be enlarged to 20 weeks of gesta-
9.3.6.9 Diffuse Uterine Leiomyomatosis (DUL) tion, and total hysterectomy is the traditional treatment of
DUL is a type of leiomyoma with special forms of growth. DUL. In recent years, hysteroscopic myomectomy was
Its main characteristic is symmetrical enlargement of the applied for the treatment of DUL in women who wish to
uterus, with numerous poor boundary small fibroids involv- preserve their uteri and expect to achieve good pregnancy
Fig. 9.69 After removal of uterine myoma, the pseudo-capsules are

Fig. 9.67 After removal of uterine myoma, pink white pseudo-capsules flushed aside and the cutting surface is seen
float in the uterine cavity
Fig. 9.68 After removal of uterine myoma, the pseudo-capsules shake Fig. 9.70 After removal of uterine myoma, the cutting surface is
in the uterine cavity along with the impact of irrigating fluid checked without obvious bleeding
Fig. 9.71 After removal of uterine myoma, there is no bleeding at the Fig. 9.73 After removal of uterine myoma, the cutting surface is cov-
base, and the pseudo-capsules do not need further resection ered by pseudo-capsules. Part of which is resected to reveal the cutting
surface and no bleeding is detected
the intramural myoma without inward protruding will not be

intervened, so that the shape of the cavity can be restored and
the damage to myometrium can be avoided.
9.3.6.10 Operating Techniques of TCRM

1. Xia reported 5-step techniques of TCRM with combina-
tion of resection and clamping. (1) Cutting: The wire loop
electrode is used to cut antegradely or retrogradely from
both ends of the maximum diameter of the free myoma,
reduce the size of myoma, and cut out an x-shape wasp-
waist dent to fit the clamping of the oval forceps. (2)
Clamping: Under the guidance of ultrasonography, the
oval forceps is inserted into the uterine cavity to clamp
the myoma and pull it backwards. (3) Twisting: the han-
dle of oval forceps is twisted clockwise or anticlockwise
to separate the myoma from its base. (4) Pulling: After
twisting the myomas for a few circles, pull backwards
with force. (5) Expulsion: In the process of pulling
backwards, the myoma descends gradually and is

Fig. 9.72 After removal of uterine myoma, there is no bleeding at cut- expulsed out from the cervix. This method can shorten
ting surface. Decrease intrauterine pressure and retract the hysteroscope the operating time effectively and is convenient for a
to check whether there is bleeding or not complete removal (Figs. 9.74, 9.75, 9.76, 9.77, 9.78,
9.79, 9.80, 9.81, 9.82, 9.83, 9.84, and 9.85).
outcomes. The surgical procedures include resection of visi- 2. There are several ways to remove the myoma fragments:
ble submucous myomas and inward-protruding intramural (1) the fragments are taken out along with the exit of wire
myomas; simultaneously the measures to stimulate the con- loop; (2) the debris is placed in between the cutting loop
traction of the uterus are taken to promote further protrusion and the inner sheath, and taken out along with the exit of
of the fibroid into the cavity. During the procedure, the nor- the inner sheath, which can reduce the times of the outer
mal endometrium shall be remained as much as possible, and sheath into and out of the cervix and uterus; (3) the
232 E. Xia et al.
Fig. 9.74 Submucous myoma which is isolated from the surrounding Fig. 9.76 Pedicle of myoma
walls
Fig. 9.77 Electrocoagulation of the roots of blood vessels so as to

Fig. 9.75 Pedicle of myoma reduce bleeding
and the irrigation fluid can rinse the tissue fragments out
myoma fragments may be brought out along with the exit from the inner sheath. In rare cases, myoma fragments
of the hysteroscope together with inner and outer sheath; could not be removed but remain in situ of the uterus,
(4) being clamped out with the oval forceps; (5) being which will either degenerate gradually, or be discharged
carried out with the myoma forceps; (6) being scraped at the first postoperative period (Figs. 9.86 and 9.87).
out with the blunt curette; (7) being sucked out with the 3. The experience of the Hysteroscopy Center of Fuxing
suction tube; (8) operative hand bracket is taken out, the Hospital, Capital Medical University, is that in the resec-
inflow pipe is connected to the valve of the outlet pipe, tion of small submucous myoma it is usually very easy to
Fig. 9.78 Resection of pedicle of myoma with wire loop electrode Fig. 9.80 A groove is cut in the upper portion of the myoma
(retrograde resection)
Fig. 9.81 A groove is cut in the lower portion of the myoma

Fig. 9.79 A groove is cut in the upper portion of the myoma
resect with wire loop electrode and vaporizing electrode. or rollerball electrode, which may reduce intraoperative
The resection of large myoma (usually more than 3 cm in bleeding. Then the myoma is resected into pieces using
diameter) needs ultrasonography and (or) laparoscopic wire loop electrode, which reduces the size of myoma.
monitoring. Prior to resection, the operator must identify Then cut off the pedicle and clamp it out, or resect the
the anatomical relationship between the myoma and its myoma completely. During operation, the monopolar
peripheral myometrial layer, and find the pedicle of blended current is used and produces a certain coagulat-
myoma. The large vessels on the surface of myoma and ing effect when cutting, which avoids the intraoperative
blood vessels in the pedicle are coagulated by wire loop bleeding. When blended current is used for cutting, it
234 E. Xia et al.
Fig. 9.82 A groove is cut in the lower portion of the myoma Fig. 9.84 The residual myoma tissues are clamped out with forceps
Fig. 9.83 Appearance of myoma after the formation of grooves Fig. 9.85 Checkup of the uterine cavity after TCRM
may cause tissue debris to adhere to electric cutting loop.

That is why some surgeons prefer the pure monopolar cutting loop remain a bit outside the sheath, so that the
cutting current. When cutting, place the wire loop at the operator can view clearly the relationship between the
back of the myoma. Then start the cutting power, and myoma and uterine wall. This can avoid cutting into the
retreat the electric wire loop till the resected tissue strip is uterine wall and injury of the internal orifice. The opera-
cut off from the myoma. This method is mostly suitable tor should be very careful in resecting the base of myoma
for the resection of submucous myoma in the center of so as not to damage the surrounding endometrium. If
uterine cavity. When cutting, it is best not to retreat the there is bleeding, coagulate the base of myoma, or use
cutting loop completely into the sheath, instead, let the tocolytic agents.
Fig. 9.86 The resected and clamped out myoma tissues (15 g weighed)
Fig. 9.88 Resection of inward-protruding intramural myoma and

identification of its pseudo-capsule
caused by changes in intrauterine pressure “rebound phe-

nomenon.” In addition, the electrical stimulation and the
clamping of myomas with oval forceps during operation
may cause the contraction of the uterus, resulting in the
thickening of the uterine muscle wall at the site of the
resected myoma, which is very helpful for a smooth
operation.
6. A 90° vertical wire loop is generally used to cut ante-
Fig. 9.87 The resected and clamped out myoma tissues (128 g
weighed) gradely with the current power of 70–120 W, and a 0°
horizontal loop is always used to resect retrogradely. For
large myomas, under ultrasonography monitoring, when
4. Osmatic cervical dilator is commonly used for cervical the operator is sure of the cut, he can cut either retro-
softening prior to TCRM. Generally, after placing the gradely or antegradely immediately after the retrograde
laminaria tent into the cervical canal at the eve of the cutting. The setting of the current power should start with
operation, the cervix will be adequately softened and lower power, and then gradually increase to the point at
dilated. It facilitates the insertion and the retraction of which the cutting loop is moving without any resistance
resectoscope, as well as the insertion of the oval forceps through the myoma tissues. The setting of the power
into the cervical canal at the time of surgery, resulting in should be regulated on the basis of easy movement of the
the decrease of operative difficulties. loop instead of using a fixed power, which can reduce the
5. For Lin’s experience, the intrauterine pressure increases possibility of breaking the cutting loop. When the current
when the hysteroscope is placed in the uterine cavity, and power is up to 120 W, the operator should drag the wire
falls suddenly when it is withdrawn. The change in pres- loop with only very small force and have a clean tissue
sure may increase the protruding degree of submucous resection. Only in a clear vision field can the current
myoma, and even helps some intramural myomas to pro- power be switched on. When resecting the intramural
trude into the uterine cavity, which are transformed into parts of the myoma, the operator must be able to identify
the submucous myoma, and are possible to be resected. the myoma from its pseudo-capsule (Figs. 9.88 and 9.89).
In addition, it has the feasibility of hysteroscopic resec- The operator can visualize the white fibrous tissues inside
tion of embedded submucous myoma. Homou named this the tumor and the glandular crypts in the endometrial tis-
phenomenon as “water massage,” and Lin calls this sues under hysteroscope, and decides on the suitable cut-
mechanical change of the protruding submucous myoma ting depth according to the identification of the rigid
236 E. Xia et al.
this successful technique and equipment to vaporize sub-

mucous myoma. In 1997, Glasser reported his prelimi-
nary experience of the application of VaporTrode in
vaporizing endometrium and submucous myomas.
Compared with the conventional techniques, the opera-
tive process is significantly shortened, a large number of
myoma debris produced are avoided, intraoperative
bleeding and absorption of irrigation fluid decrease sig-
nificantly, which reduce the dangers caused by hystero-
scopic resection. At the beginning of the vaporizing
resection of submucous myoma, the pure cutting current
should be set at power of 110 W. First, wire loop elec-
trode is used to cut 0.5 cm wedge-shaped tissues from the
top of myoma, and if the submucous myoma is invisible,
a similar resection with the same depth of the posterior
wall is performed from the uterine fundus to the internal
orifice of cervix for histopathological examination. Then,
apply the vaportrode, and increase the current power by
10 W each time, and gradually up till 200 W. Its current
power below 140 W cannot vaporize myomas. The pur-
Fig. 9.89 Resection of inward-protruding intramural myoma and
pose of vaporization of myomas is to reduce its size so
identification of its pseudo-capsule
that it could be clamped out with a grasping forceps or
resected with a cutting loop. In order to obtain some
fibrous tissues of the myoma and the surrounding soft myoma tissues for histopathological examination, the
myometrium. myoma should not be completely vaporized. A 3 mm
7. Nd-YAG laser, argon or KTP-532 laser can also be used roller barrel electrode can produce a wider vaporizing
for resection of sessile submucous myoma or submucous channel on myomas, and a 2.5 mm roller barrel electrode
myoma with a broad pedicle. Nd-YAG laser can be used can divide the myoma into blocks accurately. During the
to smash the large myomas. As for a sessile submucous process of vaporizing the myoma, there is no debris float-
myoma or a myoma with a broad pedicle, the laser or ing in the uterine cavity. It avoids the interruption of
high-frequency electricity may also destroy the residual vaporizing to remove the debris, which interferes with the
myoma tissues in the muscle wall, resulting in necrosis vision. It is only when the electrode needs to be changed
and gradual absorption. There is no comparative study on or when the forceps need to be used to remove myoma
the resection of myomas by hysteroscopic resectoscope debris that the hysteroscope is pulled out. If there is still a
and laser, respectively. small amount of residue in the superficial myometrium,
8. A 3 mm bipolar electrocoagulation needle has been used the wire loop electrode can be used for resection. Acc
in repeated (20–30 times) poking into the myoma under loop is a thick wire loop electrode equipped with a cylin-
hysteroscopy, which plays a similar role to laser in pro- der of five small grooves and with pure cutting current of
ducing. Then a 50 W coagulating electrode or 100 W cut- 275 W, which can vaporize the tissues and stop bleeding
ting current is used to act on myoma tissues, causing a lot of the cutting base. Acc loop may be used to resect the
of coagulative necrosis of myoma, interruption of blood submucous myoma with broad pedicle from the base to
supply, tissue shrinkage, and final necrosis. the level of the surrounding endometrium. The resected
9. The resection of myoma with wire loop electrode may myoma is clamped out with an oval forceps. For large
lead to significant bleeding, which may interfere with the myomas of 3–6 cm in diameter, Acc rod-shaped vaporiz-
operator’s vision. In order to have a clear vision, irriga- ing electrode with pure cutting current at power of 275 W
tion fluid needs to be administered under high pressure, is used to resect until the base of myoma. If the base is
and the fragments of myoma needs to be continuously easy to see, Acc electrode is used to vaporize from periph-
removed, which may result in prolonged operating time, ery to center. Occasionally, when the electrode with a
and also significantly increase the risk of irrigation fluid wide surface is used, the myoma can be dissected bluntly
into the blood vessels. Recently, a vaporizing electrode from its base, just like a scalpel without the use of electri-
was developed, i.e., VaporTrode, which can vaporize the cal current. The myoma fragments should be clamped out
hyperplastic and hypertrophic prostate, and is seen in the with myoma forceps or oval forceps. The myomas embed-
literature of urology. In 1995, Brooks attempted to apply ded in the myometrial layer may continue to protrude into
the uterine cavity during cutting or vaporization, and it was increased from 10.1 mm before operation to 18.8 mm
should be resected as much as possible. Even if not com- after operation. It is thought that one-stage hysteroscopic
pletely resected, it still has a high success rate. If there are myomectomy can remove the deep-set submucosal
occasionally residue tissues of myomas and persistent myoma with a thin (5 mm) myometrial layer.
menorrhagia, a second resection is required. To women
without requirements for fertility, Acc rod-shaped elec-
trode can be applied at the same time in endometrial abla- 9.3.7 Intraoperative Special Conditions
tion. Its vaporizing depth is 3–4 mm, similar to that of and Management
wire loop electrode resection. If the electrode is covered
with eschar or tissue debris, a 70 W electric coagulation 1. If there is more intraoperative bleeding, unclear vision of
current may be powered on, roll rapidly on the vaporized field, and limited operating space due to the uterine cavity
surface of the uterine cavity and it can be cleared. Prior to being filled with myoma, the use of oxytocin is inappro-
vaporization, be sure not to apply electrocoagulation of priate. This can be dealt with by adjusting the inflow pres-
the endometrium, because the inactive tissue on its sur- sure of irrigation higher than the arterial pressure and
face may produce impedance, thus hindering the vapor- increasing the flow rate. If it still does not work, connect
izing depth. After vaporization, the rollerball electrode at the outflow pipe with a vacuum extractor to produce a
power of 100 W is used to remove the endometrium at the negative pressure, which accelerates the irrigation circu-
fallopian tubal ostia and coagulate each large bleeding lation, and quickens the operation speed simultaneously.
point. The bleeding points can be easily identified when When most of the myomas are resected, bleeding will
the inflow pipe is shut to lower the intrauterine pressure. naturally decrease along with the contraction of the
The vaportrode uses the pure cutting current at high uterus.
power of 200–275 W, and this high-power vaporizing 2. After the removal of sessile submucosal myoma, the
current strengthens significantly the blockage of blood uterus contracts, the myoma bed closes, and the residual
vessels and reduces the intraoperative bleeding. Since the grayish white flocculent pseudo-capsule floats in the uter-
vaportrode may divide the myoma into blocks, there are ine cavity. Residual pseudo-capsule does not need a
few intraoperative tissue fragments and there is no need resection since they will dissolve afterwards.
to waste time to take out the tissue fragments, thus reduc-
ing the risk of excessive irrigation fluid absorption,
decreasing the occurrences of complications and increas- 9.3.8 Intra- and Postoperative Monitoring
ing the safety of the operation. Some thermal energy may and Management
cause coagulation zone of the adjacent tissues. The vapor-
izing depth depends on the contact time, impedance 9.3.8.1 Intraoperative Monitoring
(caused by the adhesion of debris on the electrode), and 1. Ultrasonography monitoring: It plays a role of guidance
the power of the current. The electrode should move in the resection of large myomas, and can also prevent
slowly on the tissues and can only be powered on when and identify uterine perforation (Fig. 9.90, 9.91, 9.92,
moving towards the operator. If such high-frequency cur- 9.93, 9.94, 9.95, 9.96, and 9.97). Recently, there have
rent is acting on a point for a long time, it is easy to cause been reports about the rectal probe for monitoring. Coccia
uterine perforation, so it is only used by the experienced et al. conducted a prospective study of ultrasonography
doctors. There have been cases of reports on hystero- monitoring of TCRS and TCRM in 81 cases, and made a
scopic operation, the myoma specimens are found to be comparison with 45 cases of laparoscopic monitoring.
leiomyosarcoma after histopathological examination. The results were that no complications occurred and there
Thus the myoma tissues should not be vaporized com- was no need to convert to laparoscopic monitoring just
pletely and part of the tissues should be kept for histo- because the ultrasonography cannot see clearly the pelvic
pathological examination. Yang and Lin reported 16 cases structure as laparoscopy. Ultrasonography is very useful
of submucous myomas which embedded deeply in the in determining the intramural portion of submucous
myometrium with the thickness between the external myoma and the boundary of the surrounding muscle
boundary of myoma and internal edge of serosa of walls, and contributes to its complete resection.
5–10 mm. The one-stage hysteroscopic myomectomy 2. Laparoscopic monitoring: It depends on the intraopera-
was performed, with myoma diameter 3.3 cm and the tive specific circumstances. For larger submucosal myo-
median weight of myoma 30 g. During the procedure, the mas, especially those that cause the distortion of uterine
myometrial thickness is increased gradually and signifi- cavity, if the operator is not sure of the safety of trans-
cantly, from 6.7 mm before operation to 16.1 mm after cervical resection, it will be safer to implement the oper-
the removal of myoma. The thickness of the opposite wall ation under laparoscopic monitoring. Laparoscopic
238 E. Xia et al.
Fig. 9.91 Transabdominal ultrasonography during TCRM. When irri-

gating the cavity with irrigation fluid, the anterior intramural myoma is
Fig. 9.90 Transabdominal ultrasonography prior to TCRM. Longitu
protruding into the uterine cavity
dinal scanning shows anterior intramural myoma
monitoring can help to find the complete and incomplete

uterine perforation in time, and can deal with it
immediately.
9.3.8.2 Postoperative Monitoring and Treatment

1. Application of prophylactic estrogen after operation: To
those who wish to conceive later, postoperative applica-
tion of estrogen can stimulate the growth of endome-
trium, accelerate re-epithelialization and prevent
occurrence of adhesion, especially for those who have
larger denude surface in uterus and in vivo low estrogen
status induced by preoperative application of GnRH ana-
logs. Second-look hysteroscopy is done 6–8 weeks post-
operation. The incidence of the endometrial adhesion
after TCRM is unknown, probably very low. Therefore,
the advantage of application of prophylactic estrogen is
not certain.
2. Transient fever: It is very rare, and the body temperature
may increase suddenly up to 40 °C within 24 h after oper-
ation. General physical examination and measurement of
white cells may find no abnormalities, and symptomatic
treatment should be followed, and the temperature mostly
return to normal within 24 h. This is commonly seen in
patients with severe anemia, and the more serious anemia
is, the higher the body temperature will be. There is no Fig. 9.92 Transabdominal ultrasonography during TCRM. The cutting
consistent view on its cause, and it is mostly agreed that it surface of the myoma appears to show strong echo
Fig. 9.93 Transabdominal ultrasonography after removal of the

myoma. The pedicle appears to show strong echo
Fig. 9.95 Transabdominal ultrasonography during TCRM. The
myoma is separated from the normal myometrium and forms circular
strong echo
is due to an allergic reaction caused by the irrigation fluid

into the body. But, in transurethral resection of the pros-
tate, the urological explanation given for this complica-
tion is transient bacteremia.
3. Abdominal pain: After operation, persistent lower
abdominal pain may develop due to uterine spasm con-
traction. A symptomatic treatment should be given and it
should be differentiated from uterine perforation.
4. Vaginal discharge: For those who have large uterine
cutting surface, large and deep myoma bed, or resection
of endometrium at the same time, before the myoma
bed heals or cutting surface is epithelialized, they may
have continuous discharge from vagina within 2 months
after operation. It may begin with a little blood, then
turn gradually to a light red blood water in 1 week, then
turn to be pale yellow watery discharge, and finally
becomes a colorless watery discharge. If the patient has
menstrual bleeding within 2 months after surgery, she
should be treated symptomatically and attention should
be paid to exclude any prolapse of residual intramural
myoma.
5. Since the intrauterine operation has a large cutting sur-
Fig. 9.94 Transabdominal ultrasonography after TCRM. An unob- face, IUD should be placed in those who still want to con-
structed and intact cavity is seen after distending with irrigation fluid ceive later after operation. If more bleeding occurs
240 E. Xia et al.
Fig. 9.96 Transabdominal ultrasonography during TCRM. The size of cir- Fig. 9.97 Transabdominal ultrasonography after TCRM. Placement of
cular strong echo shrinks, suggesting the reduction of the volume of myoma balloon for hemostasis by compression
following operation, the IUD can be taken out and 9.3.9.1 Bleeding
replaced after the next menstruation. . At the resection of type I and type II submucous myomas, and
6. To those who underwent pretreatment with GnRH ana- inward-protruding intramural myomas, if the base of the
logs, estrogen should be administered postoperatively for myoma is deep, its hemostasis will be difficult.
1 week. Electrocoagulation can be conducted for hemostasis on explicit
7. Few patients may have more menses at the first menstrual bleeding points, or the intrauterine pressure can be increased
cycle after operation. through regulating the irrigating fluid pressure to stop the
8. If there are more endometrium resected during the bleeding. If both of them do not work, insertion of a balloon
removal of myoma, those who still desire for fertility catheter should be considered, its precautions are as follows:
should undergo hysteroscopy within the second or the
third week after operation and have intrauterine adhesion 1. The amount of the fluid being injected into the balloon
removed, and other patients should have second-look should be less than the volume of the resected
hysteroscopy 4 months after operation to determine its specimens.
anatomical status. 2. The size of the balloon by ultrasonography scanning
9. Patients with type I and type II submucous myomas, and should be less than the size of the myoma prior to
patients with inward-protruding intramural myomas who operation.
require two-step operation should undergo regular ultra- 3. If the bleeding cannot be stopped by the compression of
sonography, and decide on the time for operation. the balloon, it might be due to insufficient fluid in bal-
loon. Therefore, supplementary injection of fluid into bal-
loon or 8-shaped suture of cervical external orifice with
9.3.9 Identification and Treatment thread can increase intrauterine pressure and stop bleed-
of Operative Complications ing. When the balloon catheter is stretched backward, it
can stop the bleeding from cervical canal by compres-
Loffer reported that the occurrence of complications with sion. The sutures can be removed along with the removal
TCRM is 0.5%, and 2% for nonexperienced operators. of the balloon catheter.
9.3.9.2 Uterine Perforation 9.3.9.6 Uterine Myoma Malignancy

The uterine perforation by transcervical resection of uterine If there are a few remained myoma tissues at the end of oper-
myomas often occurs in the normal myometrium adjacent to ation, the subsequent incidence of sarcoma of uterus is
the myoma. The development and extension of uterine myo- unchanged, thus its follow-up is necessary. Hansen and Lund
mas makes the adjacent myometrium stretch to be thinner, reported one case of hysteroscopic myomectomy. Under
where special attention should be paid. A passive operating hysteroscope, the intramural myoma at the uterine fundus
bracket should be used and the power cannot be turned on protruded into the uterine cavity, with the appearance of
when the vision is not clear. Hallez reported one case of uter-fibroma, and there were no other intrauterine pathological
ine perforation in 61 cases of operation. Laparoscopic repair findings identified. The tumor was removed from the myo-
was performed immediately once it was found. Corson and metrium with no operative complications, and the patient
Brooks reported that among 92 cases with hysteroscopic was discharged on the day of operation. Histopathologic
myomectomy, one case of uterine perforation occurred when examination suggested mesenchymal tumor cells invading
the resected myoma fragments were taken out. Loffer the myometrium with no obvious atypia and mitosis, and no
reported one case of uterine perforation when the resected vascular infiltration, which was diagnosed as low-grade
myoma fragments were taken out. Among 108 cases of malignant stromal sarcoma. The patient was readmitted for
TCRM performed by Wamsteker, there was one case of uter- total hysterectomy. Low-grade malignant stromal sarcoma is
ine perforation, which was cured after timely treatment. Of a rare tumor, whose symptoms and clinical manifestations
1156 cases of TCRM done by Lin, there was one case of are similar to uterine fibroma. Along with the development
uterine perforation, which occurred when the myoma was and extensive application of TCRM and TCRP, the operator
clamped out, the oval forceps mistakenly clamped and tore should be alert about this tumor, especially in young women.
the muscles at the fundus of the uterus, resulting in the In addition, it has no special high-risk signs to be identified.
perforation. Thus it is extremely difficult to make diagnosis only by diag-
nostic or operative hysteroscopy. In 1995, Marabini et al.
9.3.9.3 Fluid Overload and Hyponatremia reported a case about accidental resection of endometrial
When type I and type II submucous myoma or inward- stromal sarcoma during hysteroscopic operation. In 1996,
protruding intramural myomas were resected, the resec- Flam and Radestad reported a case of hysteroscopic resec-
tion would reach the deep myometrium with rich blood tion of submucous myoma, with its histopathological exami-
vessels, which is more likely to cause fluid overload and nation suggesting uterine endometrial stromal sarcoma.
hyponatremia than any other hysteroscopy operation.
Therefore, the operator should be highly alert. Loffer
reported that 2 of 55 cases, in which the irrigating fluid 9.3.10 Experience and Evaluation of TCRM
deficit was above 1000 mL, had transient hyponatremia,
and one of them had early pulmonary edema. Among 108 9.3.10.1 Operating Process and Outcome
cases of TCRM with 4% sorbitol as irrigation fluid reported of TCRM
by Wamsteker, one case had fluid overload, and developed 1. From 1985 to 2000, Dr. Lin totally performed 1137 cases
early pulmonary edema and hyponatremia, in which the of hysteroscopic resection of submucous myomas. The
anesthesiologist found the oxygen saturation decreased operation time ranged from 4 to 150 min. Resected speci-
and pulmonary edema. Total hysterectomy and bilateral mens varied in weight between 0.5 and 800g. There was
salpingo-oophorectomy was performed. Of Lin’s 1676 one case of uterine perforation, which was repaired under
patients by hysteroscopic electric resection, one case laparoscopy. The recurrence rates of myoma after TCRM
developed TURP syndrome. were 16.7% (38/228, from 1985 to 1992) and 8.7%
(33/378, from 1993 to 1999), respectively. In a long-term
9.3.9.4 Inversion of Uterus follow-up, 26 cases (2.6%) had total hysterectomy, six
Lin reported a case of removal of 800 g myoma, who devel- cases had transabdominal myomectomy, and 23 cases
oped postoperative uterine inversion, and underwent emer- (2.1%) underwent a second TCRM. Eighty-one pregnan-
gency abdominal hysterectomy. cies were achieved after operation, including three cases
of miscarriage, nine cases of ongoing pregnancy, and 69
9.3.9.5 Uterine Fistula cases of full-term deliveries (61 cases of vaginal birth and
De Iaco et al. reported one case of hysteroscopic resection of eight cases of cesarean section). Among 26 cases who
intramural myomas, causing uterine fistula. This 38-year-old had total hysterectomy, the indications were: enlarged
woman had uterine artery embolization due to uterine myo- intramural myomas (ten cases), uterine sarcoma (eight
mas, and underwent hysteroscopic resection 6 months later, cases), intramural myoma complicated by endometriosis
which resulted in the uterine fistula. or ovarian cyst (five cases), sessile submucosal myoma
242 E. Xia et al.
complicated by menorrhagia (two cases), and ovarian 5. In 2007, Bettocchi et al. from Italy proposed a change
cancer (one case). from “wait-and-see” to “see-and-treat” for women of
2. Vercellini et al. reported the outcomes of TCRM in 108 reproductive age with small (<1.5 cm) submucosal myo-
women over 7 years, which included 54 cases with mas. The reasons are: (1) its surface and volume of endo-
pedunculated submucous myomas, 30 cases with sessile metrium were occupied by myomas; (2) high possibility
myomas, and 24 cases with intramural myomas. For of small myomas continue to grow at reproductive age,
women with one operation, the mean operating times which may cause symptoms or complications; (3) it may
were about 18 min, 23 min, and 32 min in resecting have negative effects on spontaneous or assisted preg-
pedunculated, sessile, and intramural myomas, respec- nancy; (4) the diagnosis related to malignancy with
tively; and the fluid deficits were about 204, 278, and biopsy could not be judged reliably without the direct
335 mL in resection of those myomas, respectively. For vision; (5) The hysteroscopic “see-and-treat” is
women with more than one procedure, 14 cases were in effective.
54 cases with pedunculated myomas, 8 were in 30 cases
with sessile myomas, and 12 in 24 cases with intramural 9.3.10.2 Effects of TCRM
myomas. Twenty-seven women were found to have Tulandi and al-Took pointed out that TCRM was the best
recurrence of myomas during the follow-up of 41 method to remove the submucous myoma. For the women
months, with the recurrent rate of 34% within 3 years. who suffer from symptomatic myomas and wish to preserve
The recurrence of menorrhagia was found in 20 cases the uterus, retain or improve their fertility, TCRM has three
(ratio 30% within 3 years). The cumulative postoperative advantages over hysterectomy: (1) the shorter hospitalization
pregnancy rates within 3 years were 49% in peduncu- and lower cost; (2) the less operative pain and less morbidity
lated group, 36% in sessile group, and 33% in intramural rate; (3) if the patient has subsequent pregnancy, it is likely
group. They suggested that after TCRM, the menstrua- for her to have vaginal delivery, however there is also a risk
tion may be controlled satisfactorily, with less recurrence of rupture of the gravid uterus after TCRM. Yaron reported a
of myoma and improvement of pregnancy. For intramu- woman who underwent hysteroscopic myomectomy for sub-
ral myoma, the operating time and the number of opera- mucosal myoma, with perforation occurred at the uterine
tions required will be influenced, without long-term fundus, and suturing performed laparoscopically. Later on,
adverse outcomes. when she got pregnant, she suffered from a sudden onset of
3. Loffer made a retrospective study about the outcomes of abdominal pain at 33 weeks of gestation. Uterine rupture
TCRM in 18 postmenopausal women with bleeding and 2 with partial placenta protruding to abdominal cavity was
asymptomatic postmenopausal women with abnormal identified by laparotomy.
ultrasound findings. Of them, 19 women underwent The published literatures confirmed the effectiveness of
TCRM, including four cases of concomitant TCRE, and TCRM, and the results in short-term follow-up indicated that
one woman had hysteroscopic biopsy by resection. In a more than 90% of the excessive bleeding was under control
follow-up, it was found that three patients underwent in those who had resection of myoma alone or simultaneous
gynecologic surgeries, including one case of hysteros- removal of endometrium. As to those who had myoma resid-
copy to remove the residual myoma which was found by uals after operation, if they have no severe bleeding and (or)
ultrasonography, and two cases of hysterectomy due to a pain, about 50% of myoma residuals degenerate or discharge
sarcoma or a cervical carcinoma. It was pointed out that when following up at 3-month post-operation. If necessary,
postmenopausal women who have a submucosal myoma an “additional resection” should be conducted. In a long-
might have a higher risk for a sarcoma. term follow-up of TCRM, 22.3% of resection of submucous
4. Yen et al. reported 5 women who had DUL with multiple myoma alone developed abnormal uterine bleeding, 16.1%
numerous myomas (0.5–3 cm in diameters) and massive required further operation. On the contrary, as for those who
menorrhagia. Hysteroscopy was used to resect only myo- had resection of submucous myoma and simultaneous
mas protruding into the uterine cavity, with intramural removal of the endometrium, 22.5% developed abnormal
myomas being left in place. In total, there were ten proce- uterine bleeding, but only 8.1% required further operation.
dures performed in 5 women, including one case of hys- As for those who used Nd-YAG to remove single myoma and
teroscopic adhesiolysis due to the formation of resect the endometrium simultaneously or not, the recur-
postoperative adhesion, two cases of repeated TCRM for rence rate of menorrhagia and uterine bleeding was 2–4%.
the recurrence of the fibroids, and one case of two-step However, for those of removal of multiple submucosal myo-
TCRM with the administration of GnRH analog follow- mas and inward-protruding intramural myomas, the recur-
ing the first procedure. All five cases preserved their rence rate was 25%. For the recurrent cases, if they had no
uterus and achieved normal menses, with successful fertility desire, the most appropriate method of treatment is
pregnancies in 3 women who desired for fertility. hysterectomy. Lin’s data showed that the recurrence rate of
myoma was 16.7%. From 1993 to April of 1998, of 347cases, intraoperative complications and all were not serious. Among
26 cases (7.5%) had recurrent submucous myomas. The 84% of the patients who were followed up with the median
results of long-term follow-up were that 23 cases (2.8%) had 40 months (18–66 months), 94.4% had successful outcomes.
hysterectomy, three cases had abdominal myomectomy, and For failure cases, four had repeated operations, three under-
16 cases (2%) had another TCRM. The indications for total went hysterectomy, and four still had AUB. It was believed
hysterectomy were: enlarged myoma within myometrium in that, for selected cases, TCRM was a safe and highly effec-
ten cases, uterine myomas in six cases, intramural myoma tive procedure with long-term satisfying efficacy and fewer
with endometriosis or chocolate cyst in four cases, sessile complications.
submucosal myoma with menorrhagia in two cases, and Loffer’s studies showed that TCRM along with TCRE
ovarian cancer in one case. contributes to the improvement of bleeding symptoms. There
In 1997, Romer reported 70 cases of TCRM in women were 177 cases with uterine myoma complicated with men-
who had submucous myoma with most portions locating in orrhagia, of which only 104 cases underwent TCRM, and the
the uterine wall. GnRH analogs were administrated preop- other 73 cases applied TCRM along with TCRE. Among the
eratively for 2–3 months. With ultrasonography guidance or cases with simultaneous resection of endometrium, 95.9%
laparoscopic monitoring applied at the time of operation, had menstruation under control, while 80.8% had menstrua-
TCRM was performed by experienced surgeons. There were tion under control in those without simultaneous resection of
no intra- and postoperative complications, except for two endometrium (P = 0.003). The effects of complete resection
cases with large myomas undergoing repeated surgery. of uterine myoma were very good (P = 0.039), but the effects
Within 5–52 months of follow-up, all patients achieved nor- of simultaneous removal of the endometrium were even bet-
mal menstruation, without the requirement of hysterectomy. ter (P = 0.022). TCRE might also increase the menstrual
Thus it was thought that when resection of submucous improvement rate in those without complete resection of
myoma with their largest portion in the uterine wall was per- myomas, but there was no significant difference. The rate of
formed by experienced surgeons, the complication rate hysterectomy was not decreased by TCRE or complete
would not be increased. Hallez made a retrospective analysis resection of myoma, because the common indications for
of the outcomes in 284 cases of TCRM. The patients ranged hysterectomy were pain and dysmenorrhea rather than
in age from 25 to 70, and the diameter of myoma varies bleeding.
between 1 and 6.5 cm. There was only one case of complica- Yen et al. reported five successful cases with hystero-
tion of uterine perforation, which was immediately repaired. scopic resection for DUL. The preoperative menorrhagia
After operation, both good uterine anatomical morphology was significantly improved after TCRM. Huang et al. in the
and better function of the uterus were achieved in 95.6% of Hysteroscopy Center, Fuxing Hospital, Capital Medical
patients at 6 months after operation, 94.6% at 1 year, 89.7% University, reported that 31 infertile women who had DUL,
at 2 years, 87.8% at 3 years, 83% at 4 years, 76.3% at 5 menorrhagia, and anemia underwent TCRM under ultra-
years, 73.2% at 6 years, and being stable at 67.6% since the sound guidance. During the follow-up of mean 31.7 months,
seventh year. It was suggested that TCRM could not improve 6 women underwent repeated procedures. Three of them had
the fertility in women with primary infertility but could three procedures each. Only one patient experienced laparo-
increase it in women with secondary infertility. He believed scopic subtotal hysterectomy because of postoperative poor
that TCRM was a difficult, but safe procedure, and was a improvement of menstruation, and the other 30 patients pre-
conservative operation worthy to be adopted. In 2000, Romer served their uterus. The endometrium was repaired 2–3
et al. reported that the cases who had hysteroscopic myo- months after TCRM, with the improvement rate of menses
mectomy with myoma >3 cm in diameter and (or) intramural 93.5% (29/31) and recurrent rate of fibroids 32.3% (10/31).
myoma, or with secondary anemia were suitable for preop-
erative application of GnRH-a. The purpose of which was 9.3.10.3 Fertility After TCRM
not only to thin the endometrium, but also to reduce the size It is difficult to make a comparison due to different reports.
of myoma and the blood vessels surrounding the myoma. March, Valle, and Hallez reported that the delivery rate of
Those who had not been applied GnRH analogs had high those who had resection of submucous myoma by hysteros-
failure rates of myomectomy, especially with the large intra- copy or by laser was greater than 50%. It was thought that
mural myomas. Polena et al. conducted a retrospective anal- there was a controversy over the relationship between the
ysis of 235 cases of TCRM, which included the assessment uterine myoma and infertility. It was reported in IVF litera-
of the effectiveness of TCRM and its relationship with the ture that only the deformed uterine cavity needed operation,
type and size of myomas. The main reasons for TCRM were and the postoperative pregnancy rate of laparotomy, laparos-
AUB and infertility, with 37% of patients having endome- copy, or hysteroscopy was about 50%. Neuwirth reported
trial ablation and 32% having TCRP. Fifty-one percent of all that among 26 cases of TCRM, after operation, nine cases
patients were postmenopausal women. 2.6% of cases had required further operations, and 7 patients had hysterectomy.
244 E. Xia et al.
In view of the fact that some patients following TCRM may repeat hysteroscopic myomectomy, and two had laparotomy
have recurrent myomas, it was suggested that the patients myomectomy. Seven of 12 patients with previous infertility
who took the treatment with the purpose of pregnancy should (58%) delivered live-born infants. Derman summarized the
try to conceive within 6–8 weeks post-operation. Bernard experiences in management of submucous myomas in 94
et al. reported that the postoperative delivery rate was higher cases of AUB (94%) and infertility (16%). After TCRM, late
in women with resection of one submucous myoma than in postoperative disorders were reported in 24.5% of the
women with resection of two or more myomas, which had no patients, and further operations were performed in 15.9%.
relationship with the size and the location of submucous Within 9 years of follow-up, 83.9% of the patients did not
myomas. And in woman without intramural myomas, the need more surgery. It was suggested that the long-term cura-
delivery rate was higher and the duration between the operative effect after TCRM diminished with time although it still
tion and the delivery was significantly shorter than those had some effectiveness. After TCRM, in total 21 patients
with intramural myomas. Giatras et al. made a retrospective conceived, including two cases of spontaneous miscarriage,
analysis of the outcomes of TCRM in 41 infertile women. five cases of induced abortion, and 14 cases of full-term
After TCRM, 25 (60.9%) achieved pregnancy and 20 births. In Lin’s report of TCRM in 93 infertile patients, post-
(48.7%) delivered at term. Among them, 17 women got one operative pregnancy was achieved in 44 cases, with the
baby, 5 got twins including three cases of full-term delivery pregnancy rate 47.3%, of them three cases had spontaneous
and two cases of delivery at 33 and 35 weeks of gestation, miscarriage and 41 cases had full-term deliveries, which
and one got triplets at 31 weeks. Two women experienced included nine cases of cesarean section and 32 cases of nor-
miscarriage at 6 and 8 weeks of gestation, and another mal labor, with a full-term delivery rate of 44.1%. Wamsteker
woman developed intrauterine adhesions. It was believed reported on 49 cases of TCRM. Of 33 cases with menorrha-
that for infertile women, TCRM is an effective treatment for gia, 30 cases (91%) achieved control of postoperative bleed-
replacement of abdominal submucous myomectomy, and for ing. In 16 women who underwent TCRM due to infertility,
improvement of pregnancy. In 2008, Caliskan et al. from 9 women (56%) experienced pregnancy after surgery, with
Turkey first reported a case of myoma which was localized full-term delivery in 8 (50%). The improvement of the
on the intrauterine septum. This 43-year-old woman had symptoms was reduced with the increase of the myoma
uterine septum, double cervix and vaginal septum, who suf- impinging into the myometrium. In order to reduce the fail-
fered from primary infertility and menorrhagia. The opera- ure rate, the operator must determine preoperatively the
tions were performed in two steps. The first procedures size, number, and location of the myoma and the degree of
included laparotomy, adhesiolysis, myomectomy, and vagi- extending to the muscle layer by hysteroscopy and (or)
nal septate removal, and the second procedures involved the ultrasonography so as to determine the feasibility of
resection of complete uterine septum hysteroscopically. The TCRM. For the myoma buried in the muscle wall >50%, the
length of the cervix postoperatively was measured normal at operation is very difficult, and the myoma can be removed
26 weeks of gestation. with vaporizing electrode and Nd-YAG laser.
There are limited data from long-term follow-up. Hallez In 1999, Varasteh et al. reported on reproductive outcomes
et al. reported the outcomes of TCRM for sessile submucous after TCRM in 36 cases who experienced infertility with the
myomas in 61 cases. Among them, 93% resumed regular ages under 45 years. With the follow-up longer than 18
menstruation after operation. Of seven cases who had sec- months, the results showed that the pregnancy and live birth
ondary dysmenorrhea before operation, dysmenorrhea dis- rates in women with resected myoma larger than 2 cm were
appeared in six cases after operation. Fifty-four cases had significantly higher, and the live birth rate achieved statisti-
postoperative hysterosalpingography with 49 cases being cal significance at a myoma size more than 3 cm. It was
reported normal. Among 11 cases who had previous infertil- believed that TCRM appears to improve the ability of fertil-
ity, seven cases conceived after operation, including two ity. Although hysteroscopic resection of a large myoma
cases of early spontaneous miscarriage. Brooks et al. would remove a large area of endometrium, its advantages
reported 52 cases following TCRM and TCRP. In more than for fertility were more than the risks. Fernande et al. reported
3 months of follow-up, 91% resumed normal menstruation; the safety and efficacy of TCRM in 59 cases. After TCRM,
of 15 infertile women, 33% had pregnancies to full term. the bleeding could be effectively controlled (62%); however,
Loffer reported 53 women who underwent hysteroscopic the fertility improvement rate might be limited (with postop-
resection of intrauterine neoplasms, including 43 patients erative conception in 27%), and a full-term delivery rate of
with pedunculated or sessile submucous myomas and ten 10%. The mean age of patients was 36.6 ± 4.6 years, so the
patients with large endometrial polyps. Forty-five patients advanced age of the patients might be a factor related to
had a long-term follow-up for longer than 12 months. infertility. The factor in favor of pregnancy after operation
Excessive bleeding was controlled in 93% of the cases. Five was that myoma was the only etiology (41.6%), and the
patients (9%) underwent hysterectomy, two patients had myoma was ≥5 cm in size.
In Yen et al.’s report of five cases with hysteroscopic treat- pregnancy rate and live birth rate in women who had a his-
ment for early DUL, four conceptions achieved in 3 patients tory of infertility.
after TCRM, with three cesarean sections due to breech pre- The effects of the myomectomy on embryo implantation
sentation. Huang et al. in the Hysteroscopy Center of Fuxing and pregnancy prior to assisted reproductive treatment are
Hospital, Capital Medical University, reported 31 cases of still controversial. In 2007, Vimercati et al. from Italy studied
TCRM in women with DUL. Among 19 women who had the clinical outcomes of IVF/ICSI in 51 patients (97 treat-
infertility before operation, postoperative conception rate ment cycles) with uterine myomas, 63 cases (127 treatment
was 52.6% (10/19) and live birth rate was 47.4% (9/19). It cycles) who had previous resection of myomas, and 106
was suggested that TCRM could substitute for traditional cases (215 treatment cycles) without myomas. There were no
surgery in treatment of early DUL by improving the men- differences in pregnancy and live birth delivery between
struation, preserving the uterus and the reproductive ability. groups. Compared with the other two groups, those whose
myomas larger than 4 cm needed to increase the treatment
9.3.10.4 Repeat Operation After TCRM cycles. The results suggested that myomectomy prior to IVF
Cravello et al. reported that 49 out of 196 cases following was not indicated in women with small or middle size myo-
TCRM had a second operation and suggested that with the mas disregarding their location. In 2005, Aziz et al. from the
residual partial myomas remaining in the uterine wall, a sub- USA reported of one case who had a 6 cm intramural myoma
sequent hysterectomy or a second hysteroscopic resection of and a normal cavity detected by diagnostic hysteroscopy.
myoma was possible. Dueholm et al. reported that, in women When she conceived after IVF, intrauterine growth restric-
with myoma residuals, if there were no serious bleeding and tion (IUGR) was found in early pregnancy, which led to ter-
(or) sharp pain, 50% of the myoma residuals dissolved or mination of pregnancy at 23 weeks of gestation due to its
discharged in a 3-month follow-up post-operation, and an severe disorders, At 6 weeks after delivery, ultrasonography
“additional resection” might be done if it is necessary. From revealed a 1.7 cm intrauterine myoma, which was resected
the observation of the cases of incomplete resection of myo- hysteroscopically.
mas which embedded in the uterine wall, Valle found the
remnants of the myomas might develop necrosis, or have its 9.3.10.5 Effects of Preoperative Application
surface coated with endometrium; in a 12-month follow-up, of GnRH Analogs on the Short-
75–93% patients had their excessive bleeding under control and Long-Term Outcomes
and did not need further treatment, and 58% who once suf- Following TCRM
fered from infertility had live birth. Fernandez et al. reported Campo et al. studied 80 consecutive cases of TCRM. In
hysteroscopic resection of 286 myomas in 200 women. group A, no medication was applied in 42 cases, while in
Thirty five women underwent two or three procedures group B, GnRH analogs were given intramuscularly for 2
because the myomas were large. Complications were months in 38 cases. After TCRM, all patients were followed
encountered in 12 cases (5%), without any death or serious- up for 24 months, and assessed for the outcomes including
ness for intense care. Seventy-four percent of the patients AUB, recurrence of myomas, and repeat surgeries. The oper-
achieved improvement of the symptoms. Among women ation time in group B was significantly longer than that in
who failed to have improvement after the surgery, the predic- group A (57.65 ± 29.61 min versus 40 ± 18.06 min;
tive factors included large myomas with the size more than P = 0.002). However, there was no difference in hospitaliza-
5 cm, numerous myomas with the number more than 3, bulky tion between two groups (1.05 ± 0.22 days in group A and
uterus with the length longer than 12 cm, and type II myo- 1.15 ± 0.44 days in group B). Only one uterine perforation
mas, etc. Shokeir evaluated the reproductive outcomes in occurred. Cellular myomas without atypia were found by
follow-up of 29 cases with submucous myomas and desire histopathological examination in three patients of each
for fertility after TCRM. Among them, 14 cases had primary group. Postoperative abnormal bleeding was found in 36.3%
infertility and 15 women had a history of poor obstetric out- cases of group A, and in 26.6% cases of group B. Three cases
comes. Twenty-five cases had myomas in the uterine cavity in group A and two cases in group B had the recurrence of
(type 0), the other four cases had type 1 myomas, the size of myomas, with no statistical significance between groups.
each myoma was <5 cm, with 1.33 cm on average. There One patient from each group needed repeat hysteroscopic
were no operative complications, and most uterine anatomi- surgery. The authors concluded that, unless it was used for
cal structures returned to normal after operation. There were correction of anemia, the application of GnRH analogs could
30 postoperative pregnancies achieved in 21 women and 13 not improve the short-term and long-term outcomes. The
patients delivered 16 live births. The live birth rate increased prolonged operation time might be due to difficulty in cervi-
from 3.8% before operation to 63.2% after operation, and the cal dilatation, which needs further study to be confirmed.
miscarriage rate decreased from 61.6% before operation to Tiufekchieva et al. conducted a prospective study of 50
26.3% after operation, which indicated the improvement of women with submucous myomas who underwent hystero-
246 E. Xia et al.
scopic resection. Zoladex was given to ten women for 2

months pretreatments, with a mean decrease of the myoma
diameter 10.16 mm, which was very important for myomas
more than 30 mm in diameter. The decrease of 10 mm in
diameter indicated significant reduction of myoma volume
to be resected. Compared to the control group, the mean
operation time was decreased by 17.08 min in Zoladex
group, and 90% of the procedures were completed without
difficulties. They suggested that the administration of
Zoladex could reduce the size of the myoma, promote the
atrophy of the endometrium, and improve the conditions of
uterine cavity, leading to a fast and easy operation with less
complication.
9.4 Transcervical Resection

of Endometrial Polyps
Enlan Xia and Xuebing Peng
Endometrial polyp is a common cause of abnormal uter- Fig. 9.98 Resection of an endometrial polyp from its base with wire
ine bleeding and infertility. The traditional treatment is blind loop electrode
curettage, but the problem is that it is always difficult to
remove it.
Removal of endometrial polyps may be carried out through
a variety of devices, including fibroids forceps, curette, spe-
cialized polyps resection clamps, etc. However, with the same
operative equipment, blind intrauterine operation cannot
achieve satisfactory effects. In the past, manual mechanical
resection was carried out. If polyps are multiple, even dif-
fused in the uterine cavity, a complete curettage may be
administered. If it is a single large polyp and its pedicle is
located in the lower portion of uterus, a hysteroscope can be
applied to locate it, and then a long curved hemostat or oval
forceps can be used to clamp it out. However the endometrial
polyps with pedicles are always floating in uterine cavity, so
sometimes it is difficult to clamp them out blindly. In 1981,
Valle reported that in 179 cases who had endometrial polyps,
150 failed to have polyps removed by blind curettage.
Transcervical resection of polyp (TCRP) was performed
under direct vision, which can “have a definite object in
view,” seize and resect the endometrial polyps from the bases
of the pedicles (Fig. 9.98). Under hysteroscope, the polyps
vary in size from 0.2 to 3 cm, are single or multiple (Fig. 9.99), Fig. 9.99 Single endometrial polyp
and one polyp may have two pedicles. The appearance of a
polyp is relatively soft, bright, and shiny, with its color similar
to that of the surrounding endometrium, a bit bright red, but have pedicles, either thin and long or wide and short.
sometimes there are exceptions. Unlike endometrial debris, Occasionally, the surface of the tip of a larger polyp is accom-
polyps do not shift with the flowing of distending fluid, and panied by necrosis and appears to be purple brown. The shape
are not solid and fixed just like the submucous myoma. The of a polyp does not change with the fluctuation of uterine
shapes of polyps are mostly oval, but also can be triangular, distention pressure. The sessile polyps are often excised with
conical, or irregular. Its surface is smooth, on which the fine wire loop electrode, which may not damage the surrounding
microvascular networks can s ometimes be seen. Most polyps normal endometrium (Fig. 9.100). No matter which method
9.4.1.2 Originating from Immature Endometrium

(Nonfunctional Polyp)
The nonfunctional polyp is not sensitive to progesterone
but is still reactive to estrogen. Estrogen supports its
growth, so it can grow quite large. As the pedicle extends,
under compression of both sides of the uterine wall, the
polyp may turn flat or triangular. This polyp is yellow red,
and sometimes its distal end may be purple red due to
ecchymosis. Endometrial polyps have a strong degree of
activity, and the pressure of CO2 gas can oppress it along
the uterine wall. When contact hysteroscopy is used, it
often slips out of sight. Therefore, it may not be seen some-
times in a hurried hysteroscopy.
9.4.1.3 Adenomyoma Polyp

It is a rare type, and is characterized by the smooth muscle
within the polyp tissues, with the endometrium on its surface
being atrophy.
9.4.1.4 Postmenopausal Polyp

Fig. 9.100 Cutting surface after removal of a polyp, with no damage It is also known as atrophic polyp. After menopause, the
to surrounding normal endometrium hyperplastic or functional polyp degrades, which is similar
to the changes of surrounding endometrium. Its histologic
is used, the pedicle should be removed completely so as to features include glandular epithelial atrophy, gland duct dila-
avoid future recurrence. tation, and stromal fibrosis. Hysteroscopy can reveal a pale-
pink and opaque polyp with the vascular dilatation not
obvious, but sometimes scattered translucent vesicles and
9.4.1 Histopathological Classification dendritic dilated vessels can be seen.
Endometrial polyps may be located in any position of the

cervical canal or uterine cavity. A polyp basically consists of 9.4.2 Indications and Contraindications
endometrial glandular epithelium and stromal tissues. of TCRP
Morphology is diverse, which depends on the site where the
polyp arises and the reaction of polyp tissues to steroid hor- Indications include removal of symptomatic uterine endo-
mones. Polyps are often single, or multiple, and even fill the metrial polyps, with the exclusion of malignant changes of
uterine cavity. Polyps are varied in size, with most having polyps. Its contraindications are the same as those of
pedicles connecting to the uterine wall, but there are also ses- TCRE.
sile polyps with wide base. Polyps are conical, oval, or
finger-like protrusions, with a smooth, glossy and bright red
surface. The surface of the tip of a polyp can develop necro- 9.4.3 Preoperative Preparation
sis, hemorrhage, and superficial ulcer. and Anesthesia
9.4.1.1 Originating from Mature Endometrium The preoperative preparation and anesthesia are the same as
(Functional Polyp) those of TCRE.
The polyps originate from the responses of endometrium to
ovarian hormones, and change with the ovarian cycle. Its size
is generally small, and may partially or totally shed at the 9.4.4 Operative Procedures
menstrual period. A typical polyp is soft and has a wide base,
with its color and vessels similar to that of the surrounding 9.4.4.1 Clamping Under Hysteroscopy
endometrium, therefore it may be misdiagnosed as limited If a polyp is small, and its pedicle is located in the upper por-
endometrial hyperplasia. Contact hysteroscopy may reveal tion of uterus, especially the fallopian tubal ostia, micro
the central vascular axis of a polyp and tissue cohesion, biopsy forceps can be used to clamp it out under direct vision
therefore, the contact hysteroscopy is of great value to the of fiber hysteroscope or rigid hysteroscope. If it cannot be
diagnosis of the questionable case. removed once, repeat clamping can achieve it.
248 E. Xia et al.
9.4.4.2 Intercepting Under Hysteroscopy diameter explicitly shrunk. With the inflow of irrigation
As for the large polyps with wide pedicles near the uterine fluid, its resection is made easy.
fundus, a wire snare can be inserted by passing through the 3. At the time of resecting the polyp, a wire loop electrode
hysteroscopic operating channel into the uterine cavity under is placed at its distant end, and then start cutting. The
direct vision, and then noose the base of the polyp and then depth of cutting should reach 2–3 mm superficial myo-
rotated, thus the polyp may be removed along with the metrium beneath the pedicle (Figs. 9.105, 9.106, and
retrieval of the hysteroscope. Thereafter the hysteroscope is 9.107).
inserted again to confirm complete removal of polyps.
9.4.4.3 Hysteroscopic Electroresection

The polyps with obvious pedicles can be removed by
Nd-YAG laser. For those who have wide pedicle or sessile
polyps, and those who have persistent symptoms or recur-
rence of polyps after treatment, the hysteroscopic electrore-
section is appliable and its operative procedures are as
follows.
1. First, an observation is made of the shape and size of the

polyp and location of the pedicle (Figs. 9.101 and 9.102),
and the relationship between the base of the polyp and its
surrounding tissues (Fig. 9.103), then its cutting method
is decided.
2. Resection of multiple polyps (Fig. 9.104): If the uterine
cavity is filled with polyps, and if there is inadequate fill-
ing with irrigation fluid, which obscures its vision, the
operator can first use vacuum suction aspirator to suck
out the endometrium and polyps. If the endometrium lin-
ing the surface of polyps is sucked out, there will only be
the interstitial tissue of the polyps left with its size and Fig. 9.102 The uterine cavity before surgery
Fig. 9.101 Endometrial polyps before surgery Fig. 9.103 Basal part of a polyp
Fig. 9.106 Excised polyps (three pieces)
Fig. 9.104 Intrauterine multiple polyps
Fig. 9.107 Uterine cavity after removal of polyps
Fig. 9.105 Cutting surface seen in the excised polyp pedicle

9.4.6 Identification and Management
of Operative Complications
9.4.5 Intra- and Postoperative Monitoring
and Management Due to the limited cutting range of TCRP and the short oper-
ative time, the risks of occurrence of TURP syndrome, intra-
Intra- and postoperative monitoring and management are the uterine adhesions, and hematometra are low. In 1995,
same as those of TCRE. Marabini et al. reported one case of 26-year-old woman who
250 E. Xia et al.
underwent TCRP for AUB. The polyp had a wide pedicle, TCRP succeeded in a single procedure, with three cases con-
was 4 cm in length, and originated from the fundus and pos- ducting local anesthesia. Three complications occur, which
terior wall of the uterus. It had a smooth surface with dilated included one uterine perforation. The improvement rate of
vessels on it. Histological examination of the resected tissues symptoms after TCRP ranged from 75 to 100%. There was
showed low-grade stromal sarcoma. The patient underwent no significant difference in treatment outcomes between the
total abdominal hysterectomy and bilateral salpingo- outpatient polypectomy under local anesthesia and inpatient
oophorectomy, with the result of histological examination treatment under general anesthesia (p = 0.7).
showing no tumor cell residuals. They insisted that because Bradley et al. conducted a retrospective analysis of 201
the stroma sarcoma was difficult to be detected before sur- cases who had TCRP from 1992 to 1998. Among them, 172
gery, all lesions in uterine cavity should be resected com- cases (85.6%) had the operation indications of AUB, and
pletely, and all specimens should be sent for histological operations revealed benign endometrial polyps of 91.5%,
examination. Regarding the problem of malignant lesions, and 19 cases (9.5%) had histological abnormalities in endo-
Maltez et al. in 1998 reported one case of the focal clear cell metrial polyps, including 13 cases of complex hyperplasia,
carcinoma in a benign endometrial polyp. This patient was and six cases of atypical hyperplasia. As for the sensitivities
80-year-old and menopaused at 55 years old, without history of preoperative diagnostic tools, it was 16.7% for transvagi-
of hormone replacement therapy. Her main complaint had nal ultrasonography (TVS), 83% for sonohysterography,
been little vaginal bleeding for 1 week. The transvaginal 89.5% for hysteroscopy, and 10.8% for endometrial biopsy.
ultrasonography examination showed echoluscent areas in There were no false negative of Saline Infusion Sonography
uterine cavity, endometrial atrophy, and focal thickening (SIS) and hysteroscopy. A 30-month follow-up showed that
endometrium near the uterine fundus, which did not break 88% of the patients achieved improvement of symptoms.
through the junction of myometrium and endometrium. Tjarks et al. reported on the treatment effectiveness of differ-
Histological examination of resected polyps by hysteroscopy ent methods in 78 women with endometrial polyps. Sixty of
revealed a pedunculated polyp accompanied by dilated cys- them were successfully followed up, including two cases
tic glands, no nuclear atypia. However focal clear cell carci- being excluded for endometrial adenocarcinoma. The
noma was found in the polyps, with benign epithelial tissues remaining 58 cases included 37 premenopausal women and
around. Endometrial polyps were detected with estrogen 21 postmenopausal women, with the mean duration of fol-
receptor and expression of p53 protein for immunohisto- low-up 13 months. Twenty-six women underwent TCRP,
chemical examination. The results showed that the estrogen which was the most common. Other procedures included
receptor in benign glandular epithelium and stromal cells TCRP and TCRE, TCRP and TCRM, and hysterectomy. The
were positive and absent in clear cell carcinoma, but the results were that each operation reached high satisfaction
estrogen receptor of mesenchymal cells of the tumor tissue rates, and the menstruation decreased to at least half the
was positive with no overexpression of protein in benign length. It was believed that both simple TCRP and more
endometrial glands and stroma, while strong positive in invasive surgery could improve the symptoms of menorrha-
malignant cell nuclei. The patient underwent abdominal hys- gia and AUB. Cravello et al. reported 195 patients with endo-
terectomy and bilateral salpingo-oophorectomy. The only metrial polyps and AUB who were treated with TCRP from
reliable method for correct diagnosis is the histopathological 1987 to 1997. With a mean follow-up of 5.2 years, 80% of
examination, so it is important that the resected tissue by the patients achieved successful outcomes after TCRP. Only
hysteroscopy should be sent for histopathological 5 patients subsequently underwent hysterectomy, so they
examination. insisted that TCRP should be considered as the gold standard
for treatment of endometrial polyps. Sentilhes et al. reported
that there were no reports about uterine rupture due to preg-
9.4.7 Experience and Evaluation of TCRP nancy after TCRP. Garuti et al. evaluated the feasibility of a
“see-and-treat” office TCRP. Two hundred thirty-seven
TCRP is the only method to visualize clearly the pedicles of patients who underwent either mechanical removal or bipo-
polyps and resect them from their roots, as well as make dif- lar resection of endometrial polyps were involved in their
ferential diagnosis of the intrauterine occupying lesions. study, including 120 cases with paracervical block anesthe-
sia and 117 cases without. Twenty-six patients had to cancel
9.4.7.1 Therapeutic Effect of TCRP the procedure due to being unsuitable for office operation.
Nathani and Clark conducted a systematic review of the pub- Following operations, overall success rate was 81.2%. There
lished literatures of MEDLINE (1966–2004) in order to were no significant differences found either in success rate or
assess the efficacy of TCRP in the treatment of AUB, includ- in the visual analog scale (VAS) scores between premeno-
ing menstrual disorders, postmenopausal bleeding with or pausal and postmenopausal patients, and no significant dif-
without hormone replacement and tamoxifen therapy. All ferences found either in success rates or in VAS scores
between cases with paracervical block and cases without. In were 36 premenopausal and 64 postmenopausal patients in
parous patients, VAS scores were significantly lower and the group two, who underwent fractional curettage and histo-
rates of polypectomy were significantly higher than those in logical diagnosis of endometrial polyp, with second-look
nulliparous patients. Forty-four patients failed to undergo the hysteroscopy 12 months later. It was found by second-look
procedures, due to the intolerance of pain (18 cases) or large hysteroscopy that endometrial polyps were found in 11 cases
size of the polyp (17 cases). Clinical vasovagal reaction was of group one (13.5%), and in 46 cases in group two (46%).
the only adverse effect (1.7%), except for pain. The author Among cases with recurrent endometrial polyps, only one
held that the success rate of one-stage polypectomy was 80% occurred in case with atrophic endometrium, and no recur-
and proper selection of cases preoperation might be a reli- rence in cases with atrophic endometrial polyp. The conclu-
able option to avoid general anesthesia and TCRP. Stamatellos sion was that TCRP was superior to fractional curettage in
et al. reported that among patients who have cervical polyps, the treatment of endometrial polyp, and the recurrence risk
25% have coexisting endometrial polyps. Hysteroscopy can factors of endometrial polyp were abnormal proliferation of
be used to make an accurate diagnosis of it and perform polyps, or hyperplasia in both the polyp and the surrounding
resection. In 2005, Persin et al. reported the outcomes of endometrium.
TCRP in 283 cases, with one case (0.35%) of uterine perfo- Peng et al. from the Hysteroscopy Center of Fuxing
ration without any intervention, six cases (2.12%) with a sec- Hospital, Capital Medical University, conducted a laboratory
ond operation to complete the treatment, 3 patients (1.06%) study and confirmed that the expressions of sex hormone
with malignancy of endometrial polyp. 89.05% of all patients receptors and cytokines influencing degeneration of cells and
did not encounter any long-term complications. For the rest fibrosis of tissues had difference or significant difference
of the cases (10.95%), ultrasonography revealed endometrial with surrounding endometrium. The results of their study on
pathology, which required further treatment. Two patients women with endometrial polyps indicated that the expres-
were detected to have endometrial cancer. It was thought that sions of estrogen receptors in endometrial polyps were
vaginal ultrasound was an elementary means for the early higher and the expressions of progesterone receptors were
detection of the long-term complications following TCRP. lower than those in surrounding endometrium. The expres-
sions of vascular endothelial growth factor (VEGF) in glan-
9.4.7.2 Postoperative Recurrence of Endometrial dular cells of polyps were significantly higher than those of
Polyps glandular cells of surrounding endometrium, no matter
Reslova et al. studied the risk factors for polyp recurrence whether it is in proliferative phase or in secretory phase
and thought that TCRP could be regarded as an ideal treat- (p < 0.001); and the expressions of VEGF in stromal cells of
ment of endometrial polyps and its recurrence could be polyps were significantly higher than those of surrounding
avoided by resecting the basal layer of the endometrium endometrium in proliferative phase (p < 0.05). For trans-
beneath the polyp. Herman et al. reported about 270 cases of forming growth factor-beta 1 (TGF-β1), its expression in
operative hysteroscopy. With a follow-up to 4 years, only glandular cells of polyps were significantly higher than those
4.6% of TCRP required secondary surgery. Bacsko and of endometrium (p < 0.05); and its expression in stromal
Major reported on 163 polyps found during 1900 cases of cells of polyps was significantly higher than those of endo-
hysteroscopy. Twenty-two percent of them were found in metrium, no matter whether it is in proliferation or secretory
patients with the first dilatation and curettage (D&C) and phase (p < 0.05). It was concluded that the expression of
6.6% were found in patients with the second procedures. All VEGF and TGF-β1 was closely related to that of estrogen
of 163 polyps were removed by hysteroscopy, with the indi- and progesterone receptors, which might be the correlative
cations of hemorrhage in 55%, abnormal ultrasonography factors for the growth and development of endometrial
images in 25%, and infertility in 15%. There were two perfo- polyps.
rations (0.89%) occurring in hysteroscopic operations.
Histological examination of resected polyps revealed prolif- 9.4.7.3 TCRP Combined with TCRE to Improve
erative endometrium in 22 cases, hyperplasia in 17 cases, Therapeutic Effect
fibroid and no hormone response in 5 of each, and endome- Polena et al. reported on 367 patients that had TCRP 54% of
tritis, adenomyosis, atrophy, and malignancy in one of each. whom had TCRE simultaneously. Minor complications
They held that even though the diagnostic hysteroscopy had occurred in five cases, 83% of patients were successfully fol-
a high false positive rate, TCRP is a worthwhile method for lowed up, with the average period of follow-up 40 months
minimal invasive and organ saving surgery. Bouda et al. eval- (range from 17 to 66 months). The total success rate in all
uated the recurrence of endometrial polyp after treatment. patients was 96.4%. However, when compared with the
There were 30 premenopausal and 51 postmenopausal patients of TCRP group, it was increased in patients of TCRP
patients undergoing TCRP in group one, with follow-up by and TCRE group. Henriquez et al. conducted a retrospective
diagnostic hysteroscopy 6–12 months after TCRP. There study of TCRP in 78 consecutive premenopausal women. In
252 E. Xia et al.
a 4-year follow-up, nearly 60% of patients required further presence of endometrial polyps with the diameter less than
treatment due to postoperative abnormal bleeding. It was 1.5 cm during ovarian stimulation did not affect the out-
thought that the procedure of TCRP might be combined with comes in ICSI cycles.
TCRE or insertion of a levonorgestrel-releasing intrauterine Varasteh et al. reported the outcomes after TCRP in 23
device to improve the outcome of treatment. women who had infertility for at least 12 months and aged
under 45 years old. With the follow-up for at least 18 months,
9.4.7.4 TCRP and Infertility pregnancy and live birth rates in women after TCRP were
In 2008, Stamatellos et al. reported that 83 women who had significantly higher than that in women with normal cavities.
AUB and primary or secondary infertility from 2000 to 2005 It was concluded that TCRP might improve the reproductive
were diagnosed to have endometrial polyps by transvaginal ability of infertile women with endometrial polyps. Yanaihara
ultrasonography and diagnostic hysteroscopy. After TCRP, et al. reported that endometrial polyps were mostly located
91.6% of patients had normal menses, 61.4% of patients had on posterior uterine wall (32.0%), and the pregnancy rate
spontaneous pregnancy, and 54.2% of them achieved full- after surgery was the highest (57.4%) after resection of pol-
term delivery. No statistical differences were obtained yps located at the uterotubal junction.
between women with the diameter of the polyps up to 1 cm
and women with larger (>1 cm) or multiple polyps. 9.4.7.5 Malignancy in Endometrial Polyp
Postoperative complication rate was 2.4% and the recurrence Anastasiadis et al. conducted TVS or sonohysterography,
rate of polyps was 4.9%. It was believed that TCRP was a fractional dilatation, and curettage (D&C) to investigate
safe procedure with low complication rate, improved repro- women with AUB. Among 1415 women included, endome-
ductive prognosis, and increased pregnancy rates in women trial polyps were found in 126 patients (8.9%), including 94
with infertility which had no definite reasons. The prognosis with benign lesion, 30 (23.8%) with premalignant changes
of pregnancy had no correlation with the size or number of (complex and atypical hyperplasia) and 2 (1.5%) with
the polyps, and primary or secondary infertility. Most of malignancy, both of whom were menopausal. Bakour et al.
patients had restoration of normal menses after operation. pointed out that women with endometrial polyps were more
Gimpelson insisted that TCRP is a simple and effective commonly associated with endometrial hyperplasia. They
method for the treatment of endometrial polyps in women reported that of 62 cases who have endometrial polyps
with AUB and infertility, which can be completed in an office benign lesions were found in 53 (85.5%), hyperplasia in
setting. Xiao et al. from the Hysteroscopy Center of Fuxing seven (11.3%), and malignancy in two (3.2%). Compared
Hospital, Capital Medical University, reported that, using with endometrial specimens without polyps, hyperplasia was
cyclooxygenase-2 (COX-2) and VEGF, which were factors quite common in specimens with polyps, with 11.3% in
evaluating the receptivity of endometrium, during mid- polyp group and 4.3% in control group (p = 0.04); however,
secretory phase, the expression of them in the endometrium the incidence of malignancy was the same, with 3.2% in each
from women with endometrial polyps was lower than that in group. Ben-Arie et al. retrieved 430 consecutive cases with
normal endometrium from women without endometrial pol- endometrial polyps detected by hysteroscopy. The data
yps. It indicated that, in women with endometrial polyps, the reviewed included medical records, TVS, and histopathol-
receptivity of endometrium to the embryo was changed, ogy findings. Endometrial polyps were identified by hyster-
which might affect the embryo implantation, leading to oscopy in 95.7% of the cases. Of them, hyperplasia without
infertility in some women. In endometrial polyps and assisted atypia was found in 11.4%, premalignant conditions were
reproductive technique, Isikoglu et al. studied whether the found in 3.3%, and malignancies were found in 3.0%.
endometrial polyps detected during ovarian stimulation Although the positive predictive value for malignancy was
decreased the success rate of intracytoplasmic sperm injec- low, advanced age, menopause period, and polyps larger
tion (ICSI) cycles. Patients were divided into three groups: in than 1.5 cm were relevant factors for premalignant or malig-
group one, endometrial polyps were discovered during ovar- nant changes. In their study, all the malignant polyps diag-
ian stimulation in 15 patients; in group two, TCRP was per- nosed were in postmenopausal women, but irregular vaginal
formed prior to ICSI cycle in 40 patients with endometrial bleeding or postmenopausal bleeding was not a predictor of
polyps; and in group three, there were 956 patients without malignancy. Therefore, it was thought that endometrial pol-
polyps. There were no significant difference between the yps in postmenopausal women had a higher risk of malig-
groups in some common characteristics such as age of the nancy, and should be treated by TCRP no matter whether
patients, age of the husbands, body mass index, total dosage they had symptoms or not. Polyps smaller than 1.5 cm in
of GnRH-a, length of ovarian stimulation, peak value of asymptomatic premenopausal patients can be managed by
estradiol concentrations, endometrial thickness and number observation.
of embryos replaced, etc. Only one patient (12.5%) from the Scrimin et al. reported 16 patients who had atypical ade-
first group miscarried at early pregnancy. It indicated that the nomyomatous endometrial polyps and underwent
TCRP. After 5 years of follow-up, 13 patients were cured, 2 lems. The full-term pregnancy rate is about 45% in untreated
patients removed their uterus because of other reasons, and 1 women with either unicornuate uterus or bicornuate uterus,
died due to cardiac disorders. Endometrial adenomatous pol- and is about 40% in women with untreated septate uterus.
yps were a rare type of endometrial polyps, with its stroma The prognosis of pregnancy in women having arcuate uterus
containing smooth muscle fibers, and generally smaller pol- is a little better, with the term delivery rate about 65%. Braun
yps. In a report by Liu et al. from the Hysteroscopy Center of et al. reported that the frequency of uterine malformations
Fuxing Hospital, Capital Medical University, there were was 10% in women with infertility. Among these 10% of
1672 cases undergoing TCRP from January of 1997 to women, arcuate uterus was the most common (57.6%), fol-
February of 2006. Forty-two patients (2.51%) had endome- lowed by partial septate uterus (18.2%), bicornuate uterus
trial adenomatous polyps, of whom the postmenopausal with single cervix (10.6%), bicornuate uterus with double
women accounted for 21.43%. Five cases (11.91%) were cervixes (3.0%), complete septate uterus (6.1%), unicornu-
associated with glandular epithelial atypical hyperplasia ate uterus (3.0%), and unicornuate uterus with double vagina
(i.e., atypical polypoid adenomyoma), including mild atypi- (1.5%). Treatments are conducted in symptomatic patients,
cal polypoid adenomyoma in three cases, moderate and whose term delivery rates are quite low (5%). After hystero-
severe in one case each. The size of endometrial adenoma- scopic metroplasty, the term delivery rate was increased to
tous polyps was large, with the largest polyps of up to 6cm 75% and the live birth rate to 85%.
and the larger polyps ≥3 cm in 47.62% of the patients. All
patients were successfully followed up with the duration
ranging from 1 year to 10 years. One patient had radical hys- 9.5.1 Embryology and Classification
terectomy due to cervical cancer 2 years after TCRP, 2 of Uterine Malformations
patients had no improvement of AUB, the remaining 39
cases (92.86%) had good prognosis, with no recurrence of Uterus and fallopian tubes are all developed from parameso-
polyps. Among six cases of infertility, 1 patient of primary nephric duct (Mullerian duct). In early embryonic period, the
infertility conceived after operation and delivered at term distal portions of the paramesonephric ducts fuse. The fused
(16.67%). Five cases of atypical polypoid adenomyoma lower portions become the vagina and uterus, and the fused
were followed up for 2–7 years, 4 patients didn’t receive upper portions become the fallopian tube. This process
postoperative assisted medical treatment and hysteroscopy occurs during the fourth to sixth week of embryonic develop-
and ultrasound re-examination showed no abnormalities; ment, and is accomplished by 12th to 14th weeks. When the
one case with severe atypical hyperplasia was administered Mullerian inhibiting factor (MIF) from testis does not exist
orally large doses of medroxyprogesterone acetate 250 mg in the body, the paramesonephric ducts grow normally; dur-
q.o.d. for 6 months. After the withdrawal of medication for 5 ing the 19th to 20th week of embryonic development, uterine
months, second-look hysteroscopy showed no abnormalities, septum is completely absorbed. If not absorbed or partially
and the histopathological results of curettage showed an absorbed, incomplete septum or complete septum may result.
endometrium in proliferative phase. During the process of development and formation of the
uterus at embryonic phase, some internal or external inter-
ventions may lead to the hypoplasia or fuse barriers of
9.5 Transcervical Resection of Septum paramesonephric ducts, resulting in the formation of various
types of congenital uterine malformations.
Enlan Xia and Dan Yu The commonly used classifications of congenital uterine
malformation are the classification published by AFS in
The incidence of uterine malformations in women is 1988, and a new classification of female genital malforma-
approximately 4.3%, with about 3.5% in infertile women tions was jointly published by ESHRE and ESGE in 2013.
and about 13% in women with recurrent pregnancy loss. For details, see Chap. 8, Sect. 8.2. In this section, several
Uterine septum is the most common malformation (35%), feasible treatments of hysteroscopic metroplasty for uterine
followed by bicornuate uterus (25%) and arcuate uterus malformation are elaborated.
(20%). Uterine malformations, especially the septate uterus
itself does not seem to be a factor for infertility; however, it 9.5.1.1 Septate Uterus
can delay pregnancy and is a cause of secondary infertility. Septate uterus is an anatomical anomaly of uterus which is
In addition, there are adverse outcomes of pregnancy in those caused by disruption of fusion, lumen formation, or absorp-
who have uterine malformations, even in the early stage of tion of the paramesonephric ducts, the extent of which
pregnancy. The full-term pregnancy rate in those without any depends on disruption time. Because the uterine fusion is not
treatment of uterine malformation is only 50%, and the full- obstructed, the external contour of the uterus looks intact and
term pregnancies are often complicated with obstetric prob- need to be distinguished from bicornuate uterus. There are
254 E. Xia et al.
defects in the fusion of bicornuate uterus and the external postoperative development of pelvic adhesions, especially
contour of uterus can be partitioned. The septa that divide the ovarian and tubal adhesions. Such patients need another lapa-
uterine body are different in length and width. Some septa rotomy and uterine incision, which may cause postoperative
are thin, and some are thick with narrow uterine cavity. Some adhesions again and a second infertility. Due to the incision in
septa only divide the upper part of the cavity, and some the uterus, patients need more postoperative contraception for
extend to the internal os of the uterus. Some septa extend 3–6 months, or even longer, and those who have term preg-
even to the external os of cervix. Twenty to 25% of patients nancy require cesarean delivery. Now there is new minimally
are complicated with septate vagina. Occasionally, bicornu- invasive surgical therapy for uterine septum, namely transcer-
ate uterus is accompanied by uterine septum. vical resection of septa (TCRS). Compared with laparotomy,
Uterine septum is a very common uterine anomaly. A ret- TCRS targets and resects the septum which is the embryonic
rospective statistical analysis conducted by Zabak et al. residual tissue with fewer vessels. Therefore it causes little
showed that patients with untreated septate uterus had a poor intraoperative bleeding, has a low postoperative morbidity,
reproductive outcome, including high rate of early miscar- and is easily accepted by patients. Since the postoperative
riage, increased rate of recurrent pregnancy loss or missed epithelialized process of uterine cavity only requires 4–5
miscarriage, and increased probability of reproductive fail- weeks, the period for patients waiting for pregnancy after sur-
ure and obstetric complications. It was found that a septate gery is shortened when compared with laparotomy. In 2007,
uterus was not the reason for infertility, but increased the Lourdel from France pointed out that the septate uterus was
incidence of unexplained secondary infertility (40%). the most frequently encountered uterine malformation, which
Nowadays, hysteroscopic surgery has replaced conventional was estimated to be present in approximately 1% of infertile
laparotomy. Hysteroscopic metroplasty improves the obstet- women and in 3.3% of women with recurrent pregnancy
rical prognosis in women with septate uterus. Its advantages losses. They insisted that hysteroscopic resection of septum
lie in easier operation and low morbidity rate, avoiding the was the gold standard treatment for the septate uterus. It was
consequence of hysterotomy (such as adnexal adhesions). concluded that a TCRS was applicable for women who had
Hysteroscopic resection of uterine septum is suitable for the unidentified infertility and are more than 35 years old with no
women with a history of miscarriages (2 or more), which response to any other technique of reproduction aid, or found
could decrease the miscarriage rate to 15% post-operation. a uterine septum when undergoing a combined operation of
For infertile women, laparoscopy is also required to investi- laparoscopy and hysteroscopy for infertility, needed an
gate the pelvis for infertility, determine the type of uterine assisted reproductive technique (ART), or had a poor obstetri-
malformation, and provide an opportunity for treating any cal history. The authors also alerted that although complica-
coexisting pelvic lesions. tions of TCRS are not very frequent, it still had the risk of
Uterine septum changes the symmetry of uterine cavity, uterine rupture when patients conceived later. TCRS has the
and thus interferes with normal fertility. The traditional treat- advantages of being a simple procedure, less postoperative
ment for the women who had septum uterus and recurrent complications, and improvement of the prognosis of fertility.
pregnancy loss was traumatic surgery. Prior to the advent of Nowadays, its application has been extended from the treat-
hysteroscopy, the symptomatic uterine septum was dealt by ment of those with recurrent pregnancy loss and premature
either Jones or Tompkins transabdominal metroplasty. Jones delivery to those with infertility, especially women who want
procedure involves wedged resection of uterine fundus and to have IVF.
septum via transabdominal metroplasty, and the uterine mus-
cle wall is reconstructed, which enables more than 80% preg- 9.5.1.2 Bicornuate Uterus
nancies to continue to survive. Tompkins procedure is to During the process of embryonic development, after fusion
implement incision of uterine body in the uterine midline of two paramesonephric ducts, incomplete absorption of the
from the anterior to the posterior, excise the septate tissues middle part of the plate leads to the formation of one cervix
transversely and then make sutures. This procedure may with two uterine cavities. The upper and fundal parts of the
involve less bleeding than Jones’, and can keep a normal con- cavity present a forked-shape and the end of an unabsorbed
tour of uterine cavity without shrinkage in size. Both these plate is blunt and round. Intrauterine plate is similar to uter-
surgeries require laparotomy and incision into uterus, thus the ine septum, with its end reaching the upper, middle or lower
patients may have longer hospitalization and slow postopera- part of the cavity, or extending to the level of cervical inter-
tive recovery. The patients must use contraception for 3–6 nal os or cervical canal.
months to allow healing of uterine incisions. Those who have The frequency of bicornuate uterus is about 13.6% of
postoperative pregnancy and can maintain pregnancy to full uterine malformations, 40% of which leading to miscarriage,
term often require cesarean delivery for the prevention of premature delivery, abnormal delivery or infertility, etc.
uterine rupture. Although the postoperative pregnancy rate Traditional treatment of complete bicornuate uterus is
may be up to 82%, some patients still cannot conceive due to Strassman Metroplasty, which is to make a transverse inci-
sion along the fundus between two cornua via laparotomy till uterine cavity, broaden the endometrial areas, and improve
the cavity is exposed. Then longitudinal sutures of the cut- the reproductive outcomes.
ting surface are conducted between the left and right uterine
walls to reconstruct a uterus with normal shape. It is not an 9.5.1.4 Unicornuate Uterus
ideal therapy because of its massive trauma, incision of During the process of embryo development, one parameso-
uterus via laparotomy, prone to developing adhesions and nephric duct being well developed, but the other side having
scars, and delay of postoperative recovery. With the develop- partial or total lack of development, results in unicornuate
ment of laparoscopy and hysteroscopy, open metroplasty has uterus. The uterus well developed on one side is unicornuate;
been reasonably replaced by endoscopic metroplasty, which the one on the other side with partial development is rudi-
is to perform uterine incision and unification via laparoscopy mentary uterus. Total lack of development on the other side
and hysteroscopy. For patients with incomplete bicornuate leads to absence of rudimentary uterus.
uterus, the plate in uterine cavity is divided by hysteroscopy, Nearly 65% of unicornuate uterus coexists with rudimen-
leading to the same thickness of fundus as other uterine tary uterus, with or without communications between them
walls, which to the greatest extent restores a normal cavity. (solid, luminal, or functional cavity). Unicornuate uterus is
For incision and unification surgery of bicornuate uterus by infrequent with its incidence ranging from 1/4020 to 1/1000,
laparoscopy combined with hysteroscopy, the first step is to and take up 4.4% of congenital uterine malformations. They
use hysteroscopic resectoscope to resect intrauterine septum, have poor reproductive outcomes and 36–40% of them coex-
then cut open the myometrium and the serosa of the fundus, ist with malformation of urinary system. Occasionally,
causing an artificial perforation. The fundal wall is further homolateral ovarian hypogenesis may coexist.
incised transversely by laparoscopy till it reaches the cavity. Unicornuate uterus may cause infertility, cervical incom-
Next, bilateral cutting walls are sutured longitudinally to petence, and premature delivery, with the frequency of pri-
achieve a normal shape cavity. This surgery may achieve a mary infertility the highest. The poor reproductive outcomes
normal cavity with minimal invasive procedures, and has a include spontaneous miscarriage or premature delivery, and
good outcome with broad development prospects. lower success rate of IVF-ET. The success of fertility lies on
multiple factors, such as the blood supply of contralateral
9.5.1.3 T-Shaped Uterus uterine artery to the uterus and ovaries, the extent of myome-
T-shaped uterus is a developmental anomaly with contrac- trium defect, the degree of cervical incompetence, other dis-
tion bands formed in uterine myometrium caused by fetal eases in pelvis such as endometriosis, and the type of the
exposure to diethylstilbestrol (DES) or other external inter- unicornuate uterus. Data from literatures indicated that, in
ventions. The upper segment of the cavity is narrow, the fun- women who had unicornuate uterus, the live birth rate was
dus is arcuate with the minimal distance between the middle 15% when there is a communicating horn, 28% when there
of the fundus and two lateral walls being less than 2 cm, and is a functional non-communicating horn, 35% when there is
the middle and lower segment of the cavity is tubular with a non-communicating horn with no cavity, and 0% when
the lateral myometrium thickening, resulting in a T-shaped there is no rudimentary horn. In conclusion, the live birth
cavity. In 1980, Viscomi et al. reported the outcomes of ultra- rate is the highest in women with unicornuate uterus and
sonography in 18 women who had fetal exposure to DES, non-communicating horn with or without a cavity.
and 20 age-matched women in the control group. The results The treatment of a unicornuate uterus may apply a hys-
found that the volume of the uterus was 49.4 cm3 ± 25.5 SD teroscopic wire loop to resect the myometrium so as to
in DES exposure group, and was 90 cm3 ± 22 SD in control broaden the cavity, and postoperative pregnancy rate and live
group, which indicated that a T-shaped uterus had the char- birth rate can be increased.
acteristics of uterine dysplasia and a restricted cavity.
Women with T-shaped uterus are always present with pri- 9.5.1.5 Robert Uterus
mary infertility, miscarriage, ectopic pregnancy and/or cervi- Robert uterus is an asymmetric obstructional malformation
cal incompetence. HSG and diagnostic hysteroscopy can of complete septate uterus. In the classification system of
make the diagnosis. The indications of hysteroscopic opera- female genital malformations jointly published by ESHRE
tion for T-shaped uterus include women with a history of two and ESGE, it is in sub-class U2b. Intrauterine septum locates
or more spontaneous miscarriages, women with otherwise in one side of the uterus and completely obstructs one cavity,
unexplained infertility, and infertile women requiring leading to a blind cavity non-communicating with the vagina
assisted reproductive technique (ART). or contralateral cavity. The obstructed cavity can accumulate
Transcervical uterine incision (TCUI) can be conducted secretions or blood (hematometra), which is similar to func-
for treatment of T-shaped uterus. This involves resecting the tional rudimentary uterus in clinical manifestations, includ-
excessive myometrial tissues on uterine lateral walls or cut- ing different degrees of primary dysmenorrhea. For
ting the myometrium on bilateral walls so as to enlarge the adolescent women with severe dysmenorrhea, when Robert
256 E. Xia et al.
uterus is diagnosed, hysteroscopic resection of the septum characteristic configurations of uterine cavity in rudimentary
can be conducted. When intrauterine hematometra increases, uterus and unicornuate uterus. Laparoscopy can compensate
the blood clots can retrogradely flow to the pelvis via the fal- for the shortage of diagnostic hysteroscopy and make an
lopian tubes, followed by endometriosis and pelvic adhe- accurate diagnosis of rudimentary uterus. But occasionally it
sions, leading to infertility. Unusual conception in obstructed can be misdiagnosed as a degenerated myoma. As a rudi-
cavity may occur and can be treated by hysterotomy to mentary uterus does not communicate or communicate via a
remove the embryo. The diagnosis of a Robert uterus is dif- small hole with the vagina and contralateral cavity, its clini-
ficult because some routine investigations such as gyneco- cal symptoms occur early. Usually in puberty, women with
logical ultrasonography and HSG always misdiagnose it as rudimentary uterus will present hematocele and periodic
unicornuate uterus. A Robert uterus can be confirmed by a abdominal pain because of the obstruction to menstrual flow.
combined diagnosis with laparoscopy and hysteroscopy, and With the increase of hematocele and the enlargement of the
effectively treated by hysteroscopic resection of the septum rudimentary uterus, endometriosis or adenomyosis may
under laparoscopic monitoring. develop after the retrograde flow of menstrual blood leading
to progressive aggravation of dysmenorrhea and infertility. If
9.5.1.6 Arcuate Uterus the fallopian tube on the side of rudimentary uterus is patent,
Arcuate uterus takes up 10% of uterine malformations. Its the fertilized egg can be implanted and grow in the rudimen-
diagnosis and clinical importance are still controversial. tary uterus, resulting in rudimentary uterine pregnancy.
Taking the connecting line between two tubal os as a base Because the myometrium is hypoplastic in rudimentary
line, the diagnosis is determined by measuring the length of uterus and cannot support a bigger fetus, it will rupture spon-
the fundal protrusion into the cavity. Arcuate uterus is diag- taneously in second trimester of pregnancy, developing acute
nosed when it is less than 1.5 cm, and septate uterus is diag- abdomen.
nosed when it is 1.5 cm or longer. By 3D ultrasonography, if Park and Dominguez stated that the risk of rupture in a
the angle between bilateral endometrium of the septum is pregnant rudimentary uterine horn was high (50%), and it
acute, a partial septate uterus can be diagnosed; if it is obtuse mostly occurred in the second trimester. A pregnant rudi-
and blunt round, an arcuate uterus can be diagnosed. Zlopasa mentary uterine horn may also develop spontaneous torsion.
et al. reported that the incidence of preterm delivery was high In order to prevent torsion and rupture of a pregnant rudi-
in women with arcuate uterus. Compared with conceptions mentary uterus, Jayasinghe et al. recommended surgical
in women with other malformations, the gestational age and removal of functional rudimentary uteri before conception.
birth weight were low in women with arcuate uterus. The Removal of the rudimentary uterus can relieve dysmenor-
miscarriage rate was reduced and the delivery rate was rhea, prevent or lessen endometriosis caused by retrograde
increased after hysteroscopic metroplasty. Mucowski et al. flow of menstrual blood, and avoid pregnancy in rudimen-
reviewed the existing literatures and pointed out that there tary horn or fallopian tube. It has been commonly applied in
was insufficient evidence to conclude a correlation between women with unicornuate uterus coexisting with non-
an arcuate uterus and poor reproductive outcomes, and so communicating functional rudimentary uterus, especially in
hysteroscopic metroplasty had not been generally accepted. symptomatic women. Nakhal et al. reported on a case of
Therefore for symptomatic women, individualized treatment surgical removal of functional non-communicating rudi-
should be considered after excluding other etiology for mentary horn with remaining of the functional cervix. 2.5–6
infertility. years after the operation, the pelvic pain recurred, with large
blood-filled mass being detected at the site of previous oper-
9.5.1.7 Rudimentary Uterus ations and being confirmed to be remnant functional cervi-
When the development of two paramesonephric ducts is cal tissues. Therefore, when removing the rudimentary
asymmetric, one paramesonephric duct is dysplasia and uterus, the homolateral functional cervix should be excised
forms a luminal or solid horn, which is named rudimentary at the same time. No data has yet suggested that removal of
uterus. Usually the rudimentary uterus does not communi- the rudimentary horn can improve the reproductive out-
cate with the cervix and vagina, and does not communicate comes. In 1999, Hand et al. first reported a ruptured tubal
or communicate only via a hole with contralateral uterus. pregnancy on the side of non-communicating rudimentary
The contralateral well-developed uterus is unicornuate horn in a woman with unicornuate uterus. In 2002, Gabriel
uterus. et al. reported a case of tubal pregnancy on the side of non-
Most rudimentary uterus (solid, luminal, or functional communicating rudimentary horn in a woman with unicor-
cavity) coexist with unicornuate uterus with or without com- nuate uterus. They all provided evidence for transperitoneal
munications. Isolated rudimentary uterus with no unicornu- migration of sperm and oocyte. Therefore, if a rudimentary
ate uterus is extremely rare. 3D ultrasonography can obtain horn is not removed, the tube on its side should be ligated or
integrate coronal images of the uterus, clearly illustrate the excised.
9.5.2 Indications of TCRS 9.5.3.2 Timing of Operation

The operation must be performed during the early days after
Most women with septate uterus have normal fertility, and menstruation, lest the narrow and small uterine cavity may
only 20–25% have pregnancy failure, which may often be lined with thick endometrium, which could lead to a poor
present bleeding at the end of the first trimester of preg- visibility and difficulty in operative procedures.
nancy or at the beginning of the second trimester followed
by embryonic death. There is controversy over the relation- 9.5.3.3 Operative Preparation
ship between the septate uterus and infertility. However, On the eve before operation, a cervical dilator should be
nowadays, with the advances in the treatment of uterine inserted. If there is a complete septate uterus, it can be
malformation, primary infertility that requires assisted inserted into any one of the uterine cavities in order to
reproductive technology or intractable infertility should be achieve the purpose of softening the cervix.
considered as indications for transcervical resection of sep-
tum. Zabak’s indications refer to patients with a history of 9.5.3.4 Anesthesia
miscarriages (2 or more), patients with an unexplained A general anesthesia is administered to the patients under
infertility, and those who require assisted reproductive laparoscopic monitoring or an epidural anesthesia under
treatment. ultrasound monitoring.
9.5.3 Preoperative Preparation 9.5.4 Operative Procedures

and Anesthesia
9.5.4.1 Mechanical Resection with Scissors
9.5.3.1 Preoperative Assessment Under Hysteroscope
There are a lot of techniques to diagnose uterine malforma- It is performed using an operative hysteroscope with the
tion, including HSG, ultrasonography, hysteroscopy, MRI, outer sheath 7 or 8 mm. The irrigation fluid may contain
etc. Kupesic et al. reported that the sensitivities in the detec- electrolyte, but still a continuous irrigation device is needed
tion of septate uterus were 100% with HSG, 99.3% with for monitoring the inflow and outflow fluid in order to pre-
transvaginal color Doppler (TVCD), and 95% with vent the occurrence of body fluid overload. Hysteroscopic
TVS. Sheth et al. reported that among 36 women who were scissors can be classified into soft, half-rigid, and rigid scis-
diagnosed as bicornuate uterus on HSG, 34 cases were diag- sors. The soft scissors are not easy to control, so the half-
nosed to have intrauterine septum by laparoscopy combined rigid scissors are most commonly used (Fig. 9.108), which
with hysteroscopy. Thus there was a big diagnostic error
made by HSG, which may be associated with radiologists’
experience. MRI is a good method in diagnosing uterine
malformation, and its accuracy ranges from 95 to 100% in
diagnosing septate uterus. Prior to hysteroscopic metro-
plasty, other factors leading to pregnancy failure should be
evaluated, including: chromosome investigations on cou-
ples, midluteal serum progesterone levels, late luteal endo-
metrial biopsy for endometrial maturity, TSH for subclinical
hypothyroidism, partial thromboplastin time (PTT), anticar-
diolipin antibody (ACA) and antinuclear antibody (ANA)
for autologous and allogeneic immune conditions, human
histocompatibility locus antigen (HLA), and endometrial
biopsy to exclude chronic endometritis. As there is close
relationship between paramesonephric ducts and meso-
nephric ducts in the embryonic period, if there is uterine
malformation, malformation of urinary system shall be
excluded. However, urinary malformation does not often
coexist with uterine malformation. It has ever been reported
that uterine malformation may be concomitant with double
renal calices, nephroptosis, and other similar anomalies.
Therefore, these patients should be investigated by intrave-
nous pyelography. Fig. 9.108 Division of uterine septum with half-rigid scissors
258 E. Xia et al.
can divide the tissues directly. That is, under conditions of a late the adjacent normal endometrial tissues. The operative
good panoramic vision, the scissors can selectively divide procedures are as follows:
the tissues that need to be divided and can retreat optionally.
The procedures using half-rigid scissors do not need much 1. The diagnosis of uterine malformation depends on the
strength and skills, but it must be kept sharp and strong. The shape of uterine fundus, so it is better to perform laparos-
Hook-type scissors are most practical in the resection of copy simultaneously with hysteroscopy for diagnosis
intrauterine septa, especially those with wide and large (Figs. 9.109, 9.110, 9.111, 9.112, and 9.113) and
bases, and the residual septate tissues require small and monitoring.
superficial excision so as to avoid deep myometrial perfora- 2. Under hysteroscopy, the observation begins with the
tion. The rigid scissors can be used to divide the fibrous and sizes and morphological characteristics of the septum
broad septa. The use of this type of scissors requires excel- and uterine cavity (Figs. 9.114, 9.115, 9.116, 9.117, and
lent panoramic vision. Because these scissors have a sharp 9.118), including the distinction between complete and
tip, when cutting towards the uterine wall with force, it is incomplete septum, the tip width of the septum, the
easy to cause uterine perforation, thus the operator must be length of the septum from the fundus to its end (longitu-
very careful. dinal diameter), the length of the septum from the ante-
The application of hysteroscopic scissors in division of rior wall to the posterior wall of the uterus
uterine septum includes the accurate cutting in the midline of (antero-posterior diameter), and the size and symmetry
septum where the tissues contain fibrosis and have no blood of two uterine cavities.
vessels. Uterine myometrial vessels run from the uterine 3. When ultrasonography is applied for monitoring, the hys-
anterior and posterior walls into the septate tissues. The teroscopic wire loop may be placed at the end of the sep-
beginners should avoid cutting the posterior and anterior
walls of uterus so as to prevent unnecessary bleeding at the
time of operation. The cutting should start from one side
gradually towards the opposite side, cutting off a small piece
each time. Once the fallopian tube ostia are seen, the cutting
should be shallow, and the operator should observe carefully
the small blood vessels from the myometrial layer to avoid
penetrating the myometrium. After resecting the septum,
before the instruments are withdrawn, the fundus should be
observed under hysteroscope, and irrigating pressure should
be decreased to observe whether there is obvious bleeding. If
there is arterial bleeding, target coagulation hemostasis can
be carried out.
Scissors have the following advantages in dividing uter-
ine septum: (1) the procedure is simple and fast, and is appli-
able to all kinds of uterine septum. (2) The scissors are easily
Fig. 9.109 Septate uterus. A broad fundus is seen under laparoscope
placed at the tip of the septum. (3) Since scissors do not con-
sume electric power, the irrigation fluid containing electro-
lyte can be used so as to reduce the risk of body fluid
overload. Its disadvantage is that postoperative adhesion
may occur because the septate muscle tissues have not been
excised, thus forming acquired septum.
9.5.4.2 Transcervical Resection of Uterine

Septum (TCRS)
For TCRS, intrauterine septum is resected using needle or
wire loop electrode of hysteroscope, which uses continuous
irrigation system and has an outer sheath of 8–9 mm. The
advantages of needle or wire loop electrode in the resection
of uterine septum are that coagulation may reduce the bleed-
ing, and that continuous irrigation system irrigates the uter-
ine cavity, resulting in clear vision and simple operation. The Fig. 9.110 Septate uterus. A concave and broad fundus with slight
disadvantage is that the monopolar coagulation may coagu- indentations of anterior and posterior walls is seen under laparoscope
Fig. 9.111 Septate uterus. A slightly concave and broad flat fundus is
seen under laparoscope
Fig. 9.114 Uterine septum under hysteroscope. A distant view shows

a narrow end of the septum and two symmetrical uterine cavities similar
in size prior to TCRS
Fig. 9.112 Septate uterus. A broad fundus with flat anterior and poste-
rior walls is seen under laparoscope
Fig. 9.115 Uterine septum under hysteroscope. A closer look at the

septum reveals a longer antero-posterior diameter
Fig. 9.113 Septate uterus. A normal uterine fundus is seen under

laparoscope
by a wire loop (Figs. 9.120 and 9.121) or be divided by a
needle electrode (Figs. 9.122, 9.123, 9.124, and 9.125).
tum, its length from the fundus to the end can be measured The base of the septum at the fundus can be gradually
by ultrasonography scanning (Fig. 9.119). trimmed by a needle electrode until it is completely divided
4. A hysteroscope with the outer sheath 8–9 mm and continu- (Fig. 9.126). The excessive septate tissues in the anterior or
ous irrigation system is applied. The septum can be resected posterior walls at the fundus can be resected by a wire loop
260 E. Xia et al.
Fig. 9.118 Uterine septum under hysteroscope. It appears to be long in

antero-posterior diameter
Fig. 9.116 Incomplete uterine septum under hysteroscope. It appears

to be short in antero-posterior diameter and broad in its tip
Fig. 9.119 Uterine septum under hysteroscope. The wire loop is

placed against the end of the septum with the length of the septum mea-
sured by ultrasonography
Fig. 9.117 Uterine septum under hysteroscope. Prior to TCRS, two (Fig. 9.129) till the bilateral cornua are reached
uterine cavities appear to be asymmetrical with right cavity bigger and (Fig. 9.130), forming a flat uterine fundus (Fig. 9.131).
left cavity smaller, and the antero-posterior diameter of the septum is 6. When cutting, the operator should pay attention to its
shorter
direction and depth, keeping symmetrical incisions
between the left and the right. That is, one cut on each
(Fig. 9.127). Therefore two cavities are made open and side in turn (Figs. 9.132, 9.133, 9.134, 9.135, 9.136,
form a symmetrical uterine cavity (Fig. 9.128). 9.137, and 9.138). The symmetry of the cavity should be
5. For correction of arcuate uterus, a needle electrode is carefully kept to avoid deeper cuttings on one side which
applied to divide and trim the inward-protruding fundus deform the cavity.
Fig. 9.120 During TCRS, the wire loop is ready for resecting the Fig. 9.122 The needle electrode is placed at the end of the septum
septum
Fig. 9.121 During TCRS, the wire loop is used for resecting the Fig. 9.123 The needle electrode is making incision of the septum
septum
9.5.4.3 Hysteroscopic Resection of Septum by

7. When cutting reaches the base of septum, the operator Laser
should not cut so deep that it damages the uterine fun- Uterine septum can be divided by Nd-YAG laser, argon and
dus, otherwise it is very easy to cause perforation of KTP-532 laser. The laser does not conduct electricity, so the
uterus. fluid containing electrolyte (e.g., saline, 5% glucose saline
8. At the end of the operation, IUD is placed in the uterine solution, lactated Ringer’s solution) can be used as irrigation
cavity and taken out 2 months later. fluid, and may help to improve visibility. The division of
262 E. Xia et al.
Fig. 9.124 The needle electrode is incising the septum and approach- Fig. 9.126 The uterine fundus is trimmed by the needle electrode
ing its base
Fig. 9.127 Resection of the excessive tissues in uterine anterior wall

Fig. 9.125 The base of septum is incised by needle electrode
Hysteroscopic division of septum by laser has the follow-

uterine septum by laser should start from the end of septum ing advantages: (1) The laser can induce coagulation, so
along the midline and move from one side to the other. Be hemorrhage may be avoided. (2) Resection by laser is easy to
sure to continually move the optical fiber to avoid the occur- operate, and easier to master than hysteroscopic resecto-
rence of uterine perforation. Cho and Baggish suggested that scope. (3) There is no electrical energy transmission, so the
the laser procedure is especially suitable for the patients with fluid containing electrolyte can be used as the irrigation fluid.
wide and thick uterine septum. Its disadvantages are as follows: (1) Being expensive. (2)
Fig. 9.128 After TCRS, the bilateral uterine cornua is communicated, Fig. 9.130 The incision by a needle electrode is approaching right
forming a symmetrical uterine cavity cornu of an arcuate uterus
Fig. 9.129 The fundus of an arcuate uterus is incised by a needle Fig. 9.131 After TCRS in an arcuate uterus, the fundus is flat
electrode
9.5.4.4 Transcervical Uterine Incision (TCUI)

The laser scattered by optical fiber can do damage to the Transcervical uterine incision (TCUI) is conducted by excis-
retina of the operator, so special protective glasses need to be ing excessive myometrial tissues on bilateral uterine walls or
worn. (3) The scattered laser can damage the surrounding incising the thickened myometrium on one or two lateral
normal endometrium of septum, leading to slow epitheliali- walls to restore a normal cavity, enlarge the endometrial
zation. (4) Longer operation time. area, relieve the intrauterine pressure, and improve the uter-
264 E. Xia et al.
a b
Fig. 9.132 (a, b) The first cut from right to left with a wire loop
9.5.4.5 Uterine Unification for Bicornuate Uterus

by Combined Laparoscopy
and Hysteroscopy
The joint operation of bicornuate uterine unification via lap-
aroscopy and hysteroscopy is performed using hysteroscopic
resectoscope to resect intrauterine septum and incise the fun-
dus to its serosa under laparoscopic monitoring, forming an
artificial perforation. Then the full layer of the fundus is
transversely incised under laparoscopy. Next the incision
walls are sutured longitudinally to achieve a normal shape
cavity. For details, see Chap. 10.
9.5.5 Intraoperative Complex Conditions

and Management
As the broad and large septum may affect the operation of

hysteroscopic resectoscope and make the resection of sep-
tum difficult, the mechanical resection by microscissors or
division by laser optical fiber can be implemented. The
Fig. 9.133 The septum after the first cut resection of a complete uterine septum only requires the
resection of septum in uterine corpus. At the time of opera-
tion, a 10 mm Hegar dilator can be inserted into one cavity,
ine blood supply. Therefore, it can facilitate the implantation and the hysteroscope is inserted into another cavity to incise
of the fertilized egg, prevent miscarriage and improve repro- the septum towards the dilator just above the internal os.
ductive outcomes. This operation can be applied for treat- After cutting through the septum, the dilator is taken out and
ment of T-shaped uterus, unicornuate uterus, and Robert the operation is continued. Romer reported that a balloon
uterus. For details, see Sect. 9.8. catheter was introduced into one cavity to facilitate the hys-
a b
Fig. 9.134 The second cut from left to right. (a) A wire loop is placed on the left of the septum. (b) The wire loop resects the septum. (c) The wire
loop resects till the right side of septum
teroscopic resection of complete uterine septum. Rock et al. 9.5.6 Intraoperative and Postoperative
reported that 21 patients with complete septate uterus were Monitoring and Management
treated between 1985 and 1998 by TCRS with preservation
of cervical septum. Among 15 women who attempted to con- Since there is no boundary between the septum and the fun-
ceive after TCRS, 14 women achieved live birth babies with dus, uterine cornua are deep, and the serosa of uterine fundus
low morbidity. may be concave, TCRS may result in the perforation of uter-
266 E. Xia et al.
a b
c d
Fig. 9.135 (a) A wire loop is placed on the right of the septum and the loop seen at the midline of septum. Thus only half of the resection had
third cut from right to left is done. (b) For the third cut from right to left, been finished. (c) The fourth additional cut is done from right to left by
the wire loop is going halfway due to the broad septum, with the wire the wire loop. (d) The fourth cut is resecting in the septum
ine fundus. Therefore, it is better to administer laparoscopic place, a suitable direction of cutting is determined and guaran-
and (or) ultrasound monitoring during operation. teed, and then the wire loop is activated to resect the septum.
Transverse scanning is regularly conducted to observe whether
9.5.6.1 Ultrasound Surveillance the high echogenic band of the excised tissues is centered or
At the beginning of the operation, ultrasonography scanning is not. After removal of the septum, the cavities are cut through,
first performed to measure the length of the septum, the broad- forming a whole cavity. When the thickness of uterine fundus
ness of both the end and the base of the septum, and the thick- is 0.7–1.1 cm, it suggests that the operator should stop cutting.
ness of the uterine fundus. During procedures, under Coccia et al. conducted a p rospective study of patients who
ultrasonography surveillance, a wire loop electrode is put in underwent TCRS under ultrasonography guidance as com-
pared to patients under laparoscopic guidance. In cases under 9.5.6.2 Laparoscopic Monitoring
ultrasonography guidance, the septum had been resected more Laparoscopy is first performed to observe the external con-
extensively with short or without residual septum, and no tour of the uterus and exclude bicornuate uterus. During hys-
cases needed a second operation of resection. However in teroscopic resection, laparoscopy can monitor the procedure
cases under laparoscopic monitoring, 4 of them needed a sec- and remind the operator of potential perforation if necessary.
ond operation to resect the residual septum due to initial insuf- . When cutting is approaching the uterine fundus, put the
ficient resection. laparoscope in a proper place and dim the light. The trans-
mittance of light through uterine wall from hysteroscope can
be seen by laparoscopy. The thinner the uterine wall, when
touched with hysteroscopic electrode, the stronger the light
seen under laparoscopy. If the light of hysteroscope is obvi-
ously seen under laparoscope, it indicates a thin fundus and
suggests an impending perforation, which alerts the surgeon
to stop the operation.
Since the patients are treated for infertility, the prophylac-
tic use of antibiotics should be strengthened to prevent infec-
tions of uterine cavity or fallopian tubes. Intravenous
injection of cefotamine 1 g (or kefzol) can be administered
half an hour prior to operation, and then cephalosporins is
taken orally for 3–4 days after operation.
There is still controversy over the use of large doses of
estrogen and the placement of IUD after TCRS. Most expe-
rienced surgeons do not prefer the placement of IUD. Since
estrogen can accelerate the epithelialization of the denuded
zone in uterine cavity, large doses of estrogen may be admin-
istered after operation, such as premarin 1.25–2.5 mg, twice
per day, 30–40 days for one cycle, and progestin
medroxyprogesterone acetate (provera) 10 mg/day is added
in the last 10 days. In total, two artificial cycles are always
Fig. 9.136 The uterine fundus after resection by a wire loop
a b
Fig. 9.137 (a) The protruding crest-like tissues at uterine fundus are divided from right to left by a needle electrode. (b) A needle electrode is
incising into the protruding tissues from right to left and then moving backwards to divide it
268 E. Xia et al.
Fig. 9.138 After incision by a needle electrode Fig. 9.139 A second-look hysteroscopy checks the uterine cavity at 4
weeks after TCRS
applied. Second-look hysteroscopy should be performed at
the fourth and the eighth week post-operation to assess the
symmetry of uterine cavity (Figs. 9.139 and 9.140). If a nor-
mal cavity achieved, the patient can attempt to conceive.
9.5.7 Identification and Treatment

The detailed information is described in Chap. 12.

TCRS has become an alternative method for the treat-
ment of uterine septum, but there is a high incidence of
uterine perforation in hysteroscopic operations. Roge et al.
reported six cases of uterine perforation in 102 women
who underwent TCRS (5.8%). Chen et al. reported on two
cases of intrauterine adhesions post TCRS. A second oper-
ation may be required in patients with incomplete resec-
tion of septum found by second-look hysteroscopy. Fedele
et al. reported a comparison of 17 women who had a resid-
ual septum between 0.5 and 1 cm after TCRS and 51
women who had no residual septum or residual <0.5 cm.
The length of residual septum was measured by ultraso- Fig. 9.140 A second-look hysteroscopy checks the uterine cavity at 8
nography 1 month after TCRS. Eighteen months after weeks after TCRS
operation, 44.5% of the patients with residual septum
(0.5–1.0 cm) and 52.7% of those without residual septum Propst et al. studied 925 women who had hysteroscopic
(0 or <0.5 cm) conceived, with no significant difference; operations and found that the occurrence of complications
the delivery rate was 27.5% and 36% respectively, with no was 2.7%, which included uterine perforation, fluid overload
significant difference. It indicated that there was no sig- (≥1 L), hyponatremia, massive bleeding (≥500 mL), bowel
nificant difference in reproductive outcomes between or bladder injury, difficulty in dilating the cervix, and
women with a residual septum (0.5–1.0 cm) and women procedure-related hospitalization. TCRM and TCRS had the
with almost no residual. highest odds ratio (OR) (7.4), with fluid absorption overload
the most frequent complication. TCRP and TCRE had the eratures about case reports of uterine rupture following
lowest OR (0.1). hysteroscopic operations, with 14 cases involved. Among
them, 12 cases underwent operations for uterine malfor-
mations and eight cases encountered uterine perforation.
9.5.8 Experience and Assessment Nine cases of procedures were done by electric resection.
of Hysteroscopic Metroplasty All patients conceived between 1 month and 5 years fol-
lowing hysteroscopic operations, with an average interval
9.5.8.1 Septate Uterus of 16 months. Postoperative HSG was carried out in six
1. Therapeutic effects of TCRS: TCRS has equal or better cases with normal reports in five. Ultrasonography scan
therapeutic effects than traditional laparotomy metro- failed to detect uterine rupture during pregnancy in two
plasty in the treatment of symptomatic uterine septum. cases. Therefore, it was considered that pregnancies fol-
Liu et al. from Hysteroscopy Center of Fuxing Hospital, lowing hysteroscopic metroplasty had a high risk of uter-
Capital Medical University, made a retrospective analysis ine rupture, with which intraoperative uterine perforation
of the outcomes of TCRS in 107 patients with uterine and/or the use of electrosurgery was closely correlated
septum under ultrasonography surveillance. The mean but not an independent factor.
operation time was 21 min with no complications 2. Different operative procedures and their prognosis: In
occurred. In 97 women who were followed up success- recent years, a lot of experience has been accumulated in
fully for 5 months to 10 years, the miscarriage rate hysteroscopic metroplasty of uterine septum with
decreased from preoperative 93.10% to postoperative microscissors in Europe and the United States, and post-
29.09%, and the delivery rate increased from 3.45 to operative reproductive outcomes are similar to that with
52.73%, both with significant differences. It was believed laser. There are also some reports about comparison of
that the operation of TCRS could greatly improve the electroresection of septum with scissors and laser. It has
reproductive outcome in women with uterine septum. been reported that the postoperative pregnancy rate after
Moreover, it avoided the procedures of laparotomy and TCRS decreased by 30% because the septum could not
hysterotomy, which reduced the formation of pelvic be completely removed, especially the broad and large
adhesions and consequent pain, thus the patient had no septum. The limited resection might be related to the
limitation in physical activities. Therefore, hysteroscopy types of wire loop, especially 90° wire loop. New straight
should be considered as the optimal choice when com- or forward angle wire loop may be suitable for resecting
bined with laparoscopy and (or) ultrasonography in treat- the septum, with the postoperative outcome similar to
ment of uterine septum. Fedele et al.’s experience that with scissors and laser. Which instrument should be
suggested that the patients might conceive 4 weeks after selected depends in part on the operator’s proficiency and
TCRS and did not need to undergo elective cesarean experience in handling various situations. Most doctors
section. prefer resection with hysteroscopic scissors in treatment
The patients who conceive following TCRS may be at of uterine septum. Ohl and Bettahar-Lebugle from France
risk of uterine rupture. Creainin and Chen reported that a reported his experiences in hysteroscopic metroplasty
perforation of the fundus occurred during TCRS in a with scissors during a 7-year period in 93 women who
patient with uterine septum. The patient got a term twin had uterine septum. The results of follow-up in patients
conception after TCRS, and cesarean section revealed a with previous obstetric history showed that the premature
7 cm defect in the uterine fundus. Howe reported on a delivery rate decreased from preoperative 13 to 9.4%
29-year-old woman who had a small fundal perforation after operation, the pregnancy loss rate decreased from 78
during TCRS. When she conceived after TCRS, uterine to 24.5%, and term delivery rate increased from 5.7 to
rupture occurred at 33 weeks of pregnancy which resulted 62.3%. Cararach et al. reported the outcomes of 17 cases
in neonatal mortality and maternal morbidity. Gabriele of hysteroscopic incision of uterine septum with scissors
et al. reported a woman who conceived after complicated versus 53 cases of hysteroscopic electroresection of sep-
TCRS. Uterine rupture during labor induced with prosta- tum in women who had septa and symptoms such as
glandins E2 (PGE2) occurred, which was managed by infertility, recurrent pregnancy loss, AUB, and intractable
emergency cesarean section. An ultrasonography scan dysmenorrhea. In total, postoperative conceptions were
performed 2 years later revealed a defect of uterine wall achieved in 51 cases (73%), with the number of spontane-
which was later verified during cesarean section. The ous miscarriage, term pregnancies, and intervals between
authors hold that PGE2 is not suitable for induction of surgery and conception similar in both groups. For intra-
labor after complicated TCRS, and ultrasonography can operative complications, uterine perforation occurred in
be used for the detection of uterine defects. Sentilhes three cases of scissors group and pulmonary edema
et al. made a review of English, German, and French lit- occurred in one of electroresecting group. The authors
270 E. Xia et al.
hold that although each technique had their different (TCUI) using a needle electrode can treat the uterine mal-
advantages and more pregnancies were achieved in scis- formations resulting from a narrowed uterine cavity and
sors group, the operator’s experience was the most impor- infertility. Katz et al. reported that T-shaped uteri were
tant factor. Vercellini et al. performed TCRS in 23 women, diagnosed by HSG and hysteroscopy in eight women
including 12 patients with resectoscope (group 1) and 11 with infertility, a history of spontaneous miscarriage, or
patients with microscissors (group 2). Comparing group ectopic pregnancy. All patients were treated by incising
1 and group 2, the mean operating time was 22 ± 6 and bilateral walls hysteroscopically until a normal uterine
17 ± 5 min (p = 0.006), and the mean amount of disten- cavity was achieved without any complications occurred.
sion medium used was 890 ± 153 mL and 671 ± 170 mL After operations, four term pregnancies were achieved in
(p = 0.003), respectively. A uterine perforation occurred 3 women, one ectopic pregnancy was achieved, and no
in one woman with complete uterine septum in group 1 miscarriage happened. The authors pointed out that TCUI
which was managed conservatively. When ultrasonogra- could correct a T-shaped uterus, which could improve the
phy and hysteroscopy were carried out for follow-up 2 reproductive outcome. Serafini et al. performed hystero-
months after operation, residual septa with the depth scopic metroplasties on two cases for large septate uterus.
≥1 cm were detected and resected repeatedly in four The first patient performed the operation at the time of
patients of group 1 and two of group 2. It indicated that oocyte retrieval, and the second at the time of curettage
both methods had the same effectiveness. Assaf indicated for early spontaneous miscarriage. Both patients had
that the key points of TCRS were the surgeon’s skills and good outcomes and successful pregnancies after
the intraoperative monitoring. Excellent and prudential hysteroscopic surgery. High level of estrogen was

operation would result in a high postoperative pregnancy detected in the first case and a history of early miscarriage
rate. In order to avoid the occurrence of cervical insuffi- was in the second case, which would increase intraopera-
ciency, the septum in cervical canal was generally pre- tive bleeding and postoperative complications. The
served during TCRS in women with complete uterine authors emphasized that meticulous planning and excel-
septum. However in 2006, Parsanezhad et al. studied the lent surgical techniques could obtain success.
correlations of resecting the cervical septum during 3. Treatment of uterine septum coexisting with intrauterine
TCRS with intraoperative bleeding, cervical incompe- diseases: The intrauterine lesions should be first treated at
tence, and secondary infertility in 28 women who had the time of operation, then the uterine septum is excised,
complete uterine septum and experienced recurrent preg- thus a better visual effect of symmetric uterine cavity can
nancy loss or infertility. Patients with resection of intra- be achieved. Sometimes, the uterine septum is first
uterine and cervical septa were included in group A, and excised, and a single uterine cavity is formed, and then
patients with preservation of the cervical septum were uterine lesions are removed. In 2008, Caliskan et al. first
included in group B. The operating times in two groups reported a leiomyoma localized in the uterine septum in a
were 36.40 ± 10.67 and 73 ± 14.40 min respectively and 43-year-old woman who experienced primary infertility
the irrigation fluid deficit was 456.66 ± 165.68 mL and and menorrhagia, and had uterine septum, double cervix,
673.84 ± 220.36 mL respectively. In group B, pulmonary and a longitudinal vaginal septum. The treatment was
edema occurred in two cases, excessive bleeding arranged into two steps. In the first operation, the patient
(>150 mL) occurred in 3, and cesarean rate was higher underwent laparotomy, adhesiolysis, myomectomy, and
when compared with group A. During follow-up, there resection of the vaginal septum, and had TCRS in the sec-
was no significant difference in reproductive outcomes ond operation. When she conceived after treatment, the
between the two groups. The authors insisted that TCRS cervical length was measured at 26 weeks of gestation
including the resection of cervical septum was safe and and achieved a normal result.
easy, and was worthwhile to recommend in patients with The operator should also pay attention to whether
complete uterine septum. Hollett-Caines et al. reported there was the presence of vaginal septum or not when per-
that 26 women who had uterine septum and a history of forming TCRS. In 2007, Ziebarth et al. from America
recurrent pregnancy loss or infertility had hysteroscopic reported two cases with delayed diagnosis of partially
surgery with either bipolar needle or wire loop electrode. obstructive Mullerian anomalies. The first 30-year-old
Postoperative pregnancy rate was 95% in 19 women who woman initially experienced irregular vaginal bleeding,
had recurrent pregnancy loss, with the live birth rate 72%. dysmenorrhea, and dyspareunia. On gynecological exam-
And the pregnancy rate was 43% in seven previous infer- ination, a bulging mass in vaginal anterior wall with a
tile patients, with the live birth rate 29%. It was thought fistulous duct adjacent to the cervix was recognized.
that TCRS using either a monopolar or a bipolar electrode Blood and mucus discharged from the fistulous opening
was safe and effective, and could significantly improve when the speculum compressed the mass. The second
the live birth rate. The transcervical uterine incision 40-year-old nulliparous woman was treated for infertility
and dyspareunia, and had a history of transabdominal 7. Prophylactic TCRS: Grimbizis et al. believed that TCRS
Strassman’s metroplasty. On examination, the vaginal could be applied as a therapeutic procedure to symptom-
fornix was identified to be bulging, which was diagnosed atic women with uterine septum, and it could also be used
as oblique vaginal septum by TVS, fistulogram, and as a prophylactic procedure in asymptomatic patients, so
HSG. that it could improve their reproductive outcomes. Patton
4. Medical pretreatment prior to TCRS: Romer reported on et al. reported on 16 women who had complete septate
a comparison of pretreatment with or without a GnRH uterus, double cervix, and vaginal septum. Of these
analog. The results showed no difference in operation women, 9 complained of recurrent pregnancy loss and 7
time, fluid deficit, the occurrence of complications, the complained of dyspareunia. Procedures were performed
residual of the septum, and the pregnancy outcome. It hysteroscopically in 11 women and by laparotomy in 5.
was suggested that a GnRH-analog pretreatment was not Before treatment, the rate of pregnancy loss was 81%.
necessary for TCRS, and it could be performed in the pro- After treatment, 17 pregnancies were achieved in 12
liferative phase of the menstrual cycle. women. Three of them miscarriaged in first trimester,
5. Intraoperative monitoring: Laparoscopy is a good means with miscarriage rate 18%. Among 12 pregnancies
of monitoring in surgical treatment of symptomatic uter- achieved after hysteroscopic surgery, 9 obtained live
ine septum, which can assess accurately the contour of births (9/12, 75%). Five of 5 women who performed
uterine fundus, and clarify the diagnosis of uterine mal- modified Tompkins metroplasty conceived with no mis-
formations and detect the tubal and peritoneal lesions. carriages. Heinonen made a retrospective study and found
Ultrasonography can also be used to monitor the proce- that septate uterus was not associated with primary infer-
dure, measure the length and height of septal plate, tility, and successful pregnancy may be achieved without
observe the broadness of the tip and base of septum, and surgical treatment.
evaluate the uterine fundus at the end of operation.
Since the uterus is constantly moving during the pro- 9.5.8.2 Bicornuate Uterus
cess of resecting the septum, it is difficult to place the In 1996, Pelosi et al. first published a case report on a
ultrasound scan probe on the same plane with the hystero- laparoscopic-assisted transvaginal metroplasty for the treat-
scope or resectoscope, and track continuously the opera- ment of bicornuate uterus. Hysteroscopy was used to illus-
tive hysteroscope during the operation. It is also not easy trate the uterine cavity and reveal both the fundus and the
to find certain planes suitable for observation of uterine cornua, then laparoscopy was applied by using a monopolar
wall and uterine septum. Nevertheless, when laparoscopy needle to wedge incise the fundus between two cornua. The
is contraindicated or not suitable for use, the intraopera- uterus was taken out through vaginal posterior fornix, inte-
tive ultrasound monitoring can increase the safety of grated by suture and replaced, followed by closure of col-
TCRS. Ultrasound can also detect the obviously enlarged potomy. The patient conceived after operation and achieved
ovary or ovarian cysts. But compared with laparoscopy, a healthy live birth by cesarean section, without any defect
ultrasound does not have the advantages of simultaneous detected in uterus. In 2009, Xia et al. first reported in China
examination of pelvic structures and management of pel- about uterine metroplasty by combined laparoscopy and hys-
vic lesions. teroscopy, which could massively restore the contour of the
6. Postoperative treatment of TCRS: Milad and Valle stud- cavity and satisfy the requirement of minimum invasive sur-
ied whether the postoperative treatment with large dose gery. Now, the first women who underwent the metroplasty
of estrogen sped up the repair of the endometrium follow- surgery have obtained two healthy girls by two cesarean sec-
ing TCRS. Patients in treatment group were administered tions. Another 5 women experienced successful pregnancies
postoperative estrogen 5 mg/day for a total of 30 days, and deliveries. Of these women, one underwent cervical cer-
while patients in control group were not given any medi- clage 1 year after metroplasty, followed by successful preg-
cal treatment. Ultrasonography was conducted every nancy and live birth. In the same year, Alborzi et al. reported
week after operation and the endometrium was assessed on two cases of bicornuate uterus and two cases of duplex
in the third week. The results showed that the endome- uterus who experienced recurrent pregnancy loss. After
trium was found to be repaired in 2 of 5 cases in treatment ascertaining the double cavities hysteroscopically, laparo-
group within 1 week after operation, which suggested scopic metroplasty was conducted and good postoperative
that the treatment with estrogen after TCRS could accel- outcomes were achieved.
erate the growth of endometrium. The value of intrauter-
ine placement of an IUD following TCRS is unknown. A 9.5.8.3 T-Shaped Uterus
second hysteroscopy is done in the second or third month In 1993, Nagel and Malo first reported the outcomes of TCUI
after operation, and the residual septum <1 cm shows no in eight cases of uterine malformations who had DES expo-
clinical significance. sure. Postoperative pregnancy and live birth was achieved in
272 E. Xia et al.
5 women who had initial secondary infertility. However for 3 had no other reasons for infertility and conceived at the
women who had initial primary infertility, no postoperative eighth, fifth, and third month following TCUI respectively
conception was obtained. Later, some literatures reported on under ultrasound/laparoscopic monitoring. One woman was
a decreased miscarriage rate and an increased term delivery preoperatively misdiagnosed as intrauterine adhesions
rate following TCUI, which reached 87.5% at its highest. because diagnostic hysteroscopy just revealed one cornu,
In 2012, Xia et al. from the Hysteroscopy Center of and was diagnosed as right unicornuate uterus when under-
Fuxing Hospital, Capital Medical University first reported going combined operations of laparoscopy and hysteros-
the reproductive outcomes of TCUI on 3 women with copy. She conceived 8 months after operation and
T-shaped uterus in China, with all women achieving preg- miscarriaged at 20 weeks of gestation because of cervical
nancy and live birth after operation. In varied types of uterine incompetence.
malformations, the term pregnancy rate was the highest fol- There were several reports indicating that for women with
lowing metroplasty of T-shaped uterus (66.7%), followed by unicornuate uterus and a history of miscarriage in second tri-
complete and partial uterine septum (62.8%), and arcuate mester of pregnancy, cervical cerclage could increase the
uterus (55.6%). These data indicate the effectiveness of hys- fetus live birth rate. Golan et al. reported that cervical cer-
teroscopic metroplasty of T-shaped uterus. However, TCUI clage could decrease the preterm delivery and late miscar-
is neither the only treatment for T-shaped uterus, nor the pre- riage rates, with significant difference (P < 0.001).
ferred option, and is not recommended to the uterus with the Abramovici et al. pointed out that the cervix contained more
length of cavity less than 4 cm. This is because there may be muscle tissues and less connective tissues in women with
other factors for infertility, such as implantation, missed mis- uterine malformations, which is inadequate to resist the
carriage, preterm delivery, etc. Therefore it is generally rec- increased asymmetric intrauterine pressure in the third tri-
ommended to consider cases where uterine constriction ring mester of pregnancy, leading to miscarriage and preterm
is the only reason for infertility, failed treatment following delivery. In their study, 15 women who had uterine malfor-
diagnosis of infertility, unexplained ART failure, and unex- mations and experienced recurrent pregnancy loss received
plained recurrent pregnancy loss. There were reports on uter- cervical suture at the 11th or 12th week of gestation. All
ine perforation occurring during TCUI. In 2008, Velemir women had no clinical or radiological signs of cervical
et al. reported one case of DES intrauterine exposure who incompetence, and did not undergo any correction surgery
experienced uterine rupture at 26 weeks of gestation after for uterine malformations. After cervical operation, 13
TCUI. Moreover, Golan et al. reported that 30% of the women obtained term delivery and two experienced preterm
patients with uterine malformations had cervical incompe- delivery, with all infants alive. The authors suggested that in
tence, with the preterm delivery and late miscarriage decreas- women who suffered from infertility for uterine malforma-
ing from 50% of cases without cerclage to 21% of cases with tion, although the evidence of cervical incompetence is
cerclage (P < 0.001). Kaufman reported that in 537 women absent, before considering the surgical correction, cervical
who had DES intrauterine exposure, 178 (33%) suffered cerclage is recommended to prolong the gestational weeks
from cervical disorders. Therefore, in order to improve the and increase the fetus live birth rate. Transvaginal ultraso-
effect of treatment, cervical incompetence should be detected nography had been reported to accurately predict preterm
following hysteroscopic metroplasty for T-shaped uterus, labor, but had not been well studied in women with uterine
and prophylactic cerclage or urgent cerclage in symptomatic malformations. Airoldi et al. prospectively applied transvagi-
cases may be conducted. In Xia et al.’s report, 3 women who nal ultrasonography to evaluate the cervix at the 14th to 23rd
underwent TCUI for T-shaped uterus did neither apply pro- gestational weeks in women with uterine malformations,
phylactic cerclage, nor monitor the changes of cervical inter- with a short cervix defined as the length <2.5 cm. The results
nal os during pregnancy. They all achieved pregnancy to showed that the rates of cervical shortening and preterm
term. birth were the highest in pregnant women with unicornuate
uterus. So, for treatment of unicornuate uterus, cervical
9.5.8.4 Unicornuate Uterus incompetence should also be considered.
There are few reports on treatment for women with unicor-
nuate uterus and infertility. Markham and Waterhouse indi- 9.5.8.5 Robert Uterus
cated that the efficacy of hysteroscopic metroplasty for Dr. Xia from the Hysteroscopy Center of Fuxing Hospital,
double uterus, bicornuate uterus, and unicornuate uterus was Capital Medical University, had treated a 28-year-old woman
uncertain in reproductive outcomes, except for septate uterus. with progressive dysmenorrhea after menarche at 14 years
Xia et al. from the Hysteroscopy Center of Fuxing Hospital, old. She married 2 years after left cystectomy for chocolate
Capital Medical University, first reported in China success- cyst and salpingectomy and experienced infertility.
ful pregnancies achieved in 3 women who underwent hys- Investigation by HSG suggested right tubal blockage, with
teroscopic metroplasty for unicornuate uterus. All women no treatment followed. After two failed IVF treatments, lapa-
roscopic adhesiolysis, diathermy of endometriosis, and following various hysteroscopic procedures, such as hystero-
patency test were performed with the result being normal scopic myomectomy or resection of uterine septum. In rare
contour of uterus and right tubal patency. She conceived 3 circumstances, IUAs may be induced by uterine artery embo-
months later and underwent curettage for bleeding and inevi- lization or occlusion.
table miscarriage at 2 months of gestation, and then had hys- Patients with IUAs are always present with menstrual
teroscopic resection of Robert septum 4 days later. The abnormalities, including hypomenorrhea and amenorrhea.
patient got pregnant again 5 months after hysteroscopic When cervical internal os is mechanically obstructed, sec-
operation, and delivered a healthy girl at 39 weeks and 5 ondary amenorrhea will occur, which leads to periodic
days of gestation by cesarean section, with the weight of abdominal discomfort or pain, hematometra, and even hema-
newborn 3500 g. This is a typical case of Robert uterus, with tosalpinx. IUAs may also cause infertility. Pregnancy for
left cavity obstruction. From adolescence to fertility age, the these patients may result in spontaneous miscarriage, recur-
patient experienced the symptoms and the process of diagno- rent pregnancy loss, preterm delivery, placenta accreta, ecto-
sis and treatment including dysmenorrhea, left hematosal- pic pregnancy, etc. Moreover, there are few case reports on
pinx, left ovarian chocolate cyst, pelvic adhesions, IVF intrauterine growth restriction (IUGR) in pregnant women
failure, spontaneous pregnancy, and miscarriage. Therefore, with IUA.
hysteroscopic resection of Robert uterus is effective with IUAs are classified as endometrial adhesions, fibromus-
minimal invasion, has an easy recovery, has no scars, and is cular adhesions, and connective tissue adhesions according
in favor of postoperative conception. to its characteristics, and as central and marginal adhesions
according to its location. The severity of IUAs is divided into
9.5.8.6 Arcuate Uterus several grades on the basis of the findings of HSG and
Gergolet et al. carried out a prospective study to compare the diagnostic hysteroscopy (see Chap. 8, Sect. 8.2). At present,
outcome of hysteroscopic metroplasty on septate uterus and the most widely used classification of IUAs in the world is
arcuate uterus. Preoperative miscarriage rates in both groups the classification system proposed by American Fertility
were high, which significantly decreased after operation, and Society (AFS) in 1988 and the classification system estab-
were similar postoperatively between the two groups (14% lished by European Society of Gynecological Endoscopy
in septate uterus and 11% in arcuate uterus). Therefore it was (ESGE) in 1995.
concluded that the pre- and postoperative reproductive out- Ultrasonography (US), three-dimensional ultrasonogra-
comes of hysteroscopic metroplasty in arcuate uterus were phy (3D-US), sonohysterography (SHG), hysterosalpingog-
similar to those in septate uterus. raphy (HSG), magnetic resonance imaging (MRI), and
diagnostic hysteroscopy are commonly used investigations
for diagnosis of IUA. Before the advent of hysteroscopy,
9.6 Transcervical Resection HSG was the first-line investigation to reveal the contour of
of Intrauterine Adhesions the uterine cavity. HSG can illustrate the areas of adhesive
occlusion, display the special filling defects, and even pro-
Dan Yu vide assessments of uterine cornua, tubal contours, and tubal
patency. Ultrasonography has been used to diagnose fibrosis
Intrauterine adhesion (IUA) refers to the formation of of endometrium or adhesions in uterine cavity, and display
endometrial fibrosis or adhesive band, resulting from the the uterine cavity which cannot be detected by HSG or hys-
damage to the basal layer of endometrium, which is mostly teroscopy, so it is now commonly used in preliminary screen-
following the trauma to a gravid or non-gravid uterus. It is ing of IUAs. MRI has also been used to investigate IUAs,
known that trauma to a gravid uterine cavity was the main especially in patients who have difficulties to be diagnosed
cause of IUA. Such trauma could be induced by uterine hysteroscopically or have total atresia of the cervical canal.
curettage due to excessive bleeding 1–4 weeks postpartum or Diagnostic hysteroscopy can reveal the intrauterine adhe-
after miscarriage. During this vulnerable phase, the basal sions under direct vision, confirming the extent and the
layer of endometrium is easily damaged by any trauma, degree of adhesions and determining the quality of the endo-
which promotes the uterine walls adhering to each other and metrium, which permit the diagnosis of IUAs more accu-
leads to the formation of permanent adhesions, the distortion rately. Therefore, diagnostic hysteroscopy has been
of uterine cavity, and the absence of its symmetry. Secondly, considered as the gold standard for diagnosis of IUAs.
trauma to a non-gravid endometrium can also result in IUAs can be treated by surgical division or resection of
IUA. It was reported that IUAs may occur after diagnostic adhesions. In the past, blind division of adhesions has been
curettage, abdominal myomectomy, cervical biopsy, endo- carried out with curettes, probes, or dilators. Such treatment
metrial polypectomy, intrauterine placement of IUD, or the of blind division of adhesions cannot bring about a satisfying
treatment with radium. In addition, IUAs may also happen clinical result, and the postoperative reproductive outcome is
274 E. Xia et al.
disappointing. Moreover, hysterotomy with division of adhe-

sions under direct vision has been attempted and described.
However, this technique has failed to produce acceptable
postoperative outcomes and has been mostly abandoned. The
current standard method for treatment of IUA is transcervi-
cal resection of intrauterine adhesions (TCRA). It can enable
dividing or dissecting intrauterine adhesions under direct
vision, which helps to restore normal menstruation after
treatment, and improves the outcomes of pregnancy and
delivery. It involves not only restoring the shape of uterine
cavity via hysteroscopic surgery, but also enhancing the
repair and regeneration of endometrium by various methods
to prevent reformation of adhesions.
Fig. 9.141 Transvaginal ultrasound scanning of uterus. It shows that
the uterus is in a retroverted position and 45 mm × 53 mm × 40 mm in
size. The myometrial echotexture is homogeneous. The endometrium is
9.6.1 Operative Indications isoechogenic and in midline with its thickness 8 mm and the continuity
and Contraindications interrupted. These appearances suggest the diagnosis as intrauterine
adhesions
9.6.1.1 Indications
Any conditions in association with IUA, such as abnormal
menstruation, dysmenorrheal, infertility, and pregnancy fail-
ure, are operative indications. And the following conditions
should be considered as well:
1. Histological examination of endometrial biopsy shows no

malignancy.
2. The size of uterus ≤9 weeks of gestation, and the length
of cavity ≤12 cm.
9.6.1.2 Contraindications
1. Cervical canal cannot be fully dilated because of cervical
scarring.
2. The hysteroscope cannot reach the fundus due to extreme
bending of the uterus.
3. The acute stage of genital tract infections.
4. The acute period of organ failure which includes heart,
liver, and kidney.
9.6.2 Preoperative Preparations
1. Preoperative preparations include the inquiry of a detailed Fig. 9.142 Inspection of uterine cavity under hysteroscopy. It shows
an abnormal cavity. An adhesive band is seen in the middle part of the
history and the assessments of comprehensive examina-
cavity, which is cylindrical, located slightly to the left, and connects the
tions before hysteroscopic adhesiolysis. Ultrasonography anterior and posterior walls of the uterus. These appearances suggest
can help to evaluate the size, shape, location, and echoes the diagnosis as intrauterine adhesions (central)
of the uterus, and to investigate the direction of the uter-
ine lines, thickness of the endometrium, and pelvic 2. In general, the ideal time for operation is in the early pro-
masses of adnexa (Fig. 9.141). Diagnostic hysteroscopy liferative phase of the menstrual cycle. A cervical osmotic
permits the inspection of the shape of uterine cavity, the dilator or a laminaria tent should be inserted into the cer-
characteristic of endometrium, and the degree of adhe- vical canal on the night before operation. When insertion
sions, as well as any other occupying lesions. Histological of a tent is difficult or the uterine cavity is fully occluded,
biopsy under direct vision can be performed simultane- a 400 μg misoprostol tablet can be inserted into the poste-
ously to exclude malignant lesions (Fig. 9.142). rior fornix of the vagina.
3. On the morning of operation, the patient should have

fasted and held in urine so as to facilitate ultrasound mon-
itoring during the surgical procedure. Prior to operation,
the operator should make ready all instruments and
devices which will be used in surgical procedures, and
make sure they are in good conditions. The patient is
placed in lithotomy position. Operating area is disin-
fected and the osmotic dilator is removed if it has been
used.
9.6.3 Anesthesia
The choice of anesthesia for hysteroscopic adhesiolysis

depends on the type and duration of the operation.
Hysteroscopic lysis for mild adhesions may apply intrave-
nous anesthesia because of the short operating time. Epidural
anesthesia can be considered in patients who have contrain-
Fig. 9.143 After filling the bladder, sound the cavity using a probe
dications of intravenous anesthesia or need to have more
under ultrasound monitoring. When the probe cannot reach the fundus,
complex procedures. General anesthesia can be chosen in ultrasonography would guide the probe going forward
patients who have to have very difficult procedures resulting
in the possibility of pelvic organ injury, or in patients who
have laparoscopic monitoring / laparoscopic surgery simul-
taneously with hysteroscopy.
9.6.4 Surgical Procedures
9.6.4.1 Transcervical Resection of Intrauterine

Adhesions (TCRA)
Surgical procedures of TCRA vary on the basis of severity
and location of IUAs. Filmy and loose adhesions may be
mechanically divided with the sheath of the hysteroscope.
Dense and firm adhesions can be dissected hysteroscopi-
cally. The principles of the surgery are to restore a normal
uterine cavity, to reveal bilateral uterine cornua and fallo-
pian tubal ostia, and to reduce the damage to the residual
endometrium. Extensive intrauterine adhesions may not be
completely divided by the primary operation, and need mul-
tiple procedures. The detailed procedures are as follows:
1. Firstly, fill the bladder moderately, scan the uterus with

transabdominal ultrasonography, insert the probe care- Fig. 9.144 Visualization of intrauterine endometrial adhesive band
fully, and then dilate the cervix gradually with Hegar under hysteroscopy
dilators. If the probe cannot approach the fundus due to
cervical atresia, or the probe can only reach into the cer- canal. The shapes of cervical canal and uterine cavity,
vical canal, the adhesions could be divided by hystero- the conditions of bilateral uterine cornua and tubal ostia,
scopic surgery afterwards. Alternatively, a probe could and the characteristics of adhesions are all observed
be pushed ahead harder along the midline of cervix and under direct vision (Figs. 9.144 and 9.145).
uterus to reach the fundus under the guidance of ultraso- 3. New and loose endometrial adhesions in either cervical
nography (Fig. 9.143). canal or uterine cavity can be divided mechanically by
2. With ultrasound guidance, the hysteroscope is inserted pushing forward the sheath tip of the hysteroscope
into uterine cavity through cervical os and cervical (Fig. 9.146).
276 E. Xia et al.
Fig. 9.145 Visualization of intrauterine scar tissues under Fig. 9.147 Adhesive scar tissue in cervical canal is divided by hystero-
hysteroscopy scopic needle electrode
5. Extensive adhesions at fundus can be transversely

divided by needle electrode or transversely resected by
wire loop electrode, both of which move towards the
cornua and completely open the fundus (Fig. 9.148a, b).
6. Procedures of hysteroscopic adhesiolysis try to open
bilateral cornua and reveal both tubal ostia. In general,
the adhesive bands at cornua are divided by needle elec-
trode under ultrasound monitoring. If it is necessary, cut-
ting loop could be used to resect adhesion tissues as a
supplementary method. At the end of procedures, bilat-
eral cornua and both tubal ostia can be seen, and normal
shapes of bilateral cornua are restored (Figs. 9.149a–d
and 9.150a–d). Moreover, it is important to protect nor-
mal endometrium at the area of both cornua.
7. Central fibrous scar tissues in uterine cavity can be
excised by hysteroscopic cutting wire loop electrode
(Fig. 9.151). Dense central fibrous scar tissues can also
be divided by hysteroscopic needle electrode
(Fig. 9.152).
8. Scar tissues at anterior, posterior, and bilateral walls of
Fig. 9.146 Intrauterine adhesive band is divided mechanically by the uterine cavity may be incised along longitudinal axis of
sheath tip of the hysteroscope uterus by needle electrode. They could also be excised
by cutting loop if necessary (Figs. 9.153a, b and
9.154a–c).
4. Dense fibrous adhesions in cervical canal can be divided 9. For patients who have a narrowed cavity coming from
by needle electrode or dissected by wire loop electrode constricting scars of uterine walls, needle electrode can
of hysteroscopic resectoscope (Fig. 9.147). be used to incise the scar tissues longitudinally 4–5
a b
Fig. 9.148 (a) Vertical adhesive bands at fundus are transversely divided by hysteroscopic needle electrode. (b) All adhesions at fundus are
divided by hysteroscopy
times along the long axis of uterus to increase the vol- ity by using flexible semi-rigid or rigid scissors, so that
ume of cavity (Fig. 9.155a–c). the cavity can be broadened. In cases of total atresia of
10. In patients with atresia of the uterine cavity, a blind end uterine cavity, cutting starts at cervical internal os and
may be seen in front of the hysteroscope. The operation moves towards the cavity gradually to approach the fun-
on these patients should be performed under ultrasound dus and bilateral cornua, until a newly formed cavity is
guidance, by pushing gently forwards either the electri- achieved (Fig. 9.160a–d).
fied needle electrode or the wire loop electrode along the 2. The advantages of hysteroscopic surgery with scissors
midline of cervix and uterus. This is to excise some are:
adhesions, cut to open holes, and reveal the uterine cav- (a) It cuts adhesions mechanically, which provides
ity (Fig. 9.156a–c). Afterwards, intrauterine adhesions excellent view of adhesions, especially those close to
are removed following procedures mentioned above the myometrium. Bleeding might be observed when
until a normal uterine cavity is achieved (Fig. 9.157). the cutting reaches the myometrium, which alerts the
11. When the procedure is about to end, the resectoscope surgeon to stop further cutting so as to avoid
should be retracted back to the level of cervical internal perforation.
os and the shape and symmetry of uterine cavity are (b) In cases with extensive adhesions, there will be little
observed (Fig. 9.158). normal and healthy endometrium, and it will be very
12. In patients who take laparoscopic monitoring, methy- important to preserve it. The dissection with scissors
lene blue solution could be injected into the uterine cav- may not lead to either the formation of scar tissue or
ity to test the fallopian tubal patency, which can be the destruction of normal endometrium produced by
observed under laparoscope (Fig. 9.159). resection with electricity or laser. Therefore opera-
tions with scissors can maximum preserve the
9.6.4.2 Hysteroscopic Lysis of Adhesions endometrium.
with Scissors 3. The disadvantages of hysteroscopic surgery with scissors
Many gynecologists like to use hysteroscopic scissors to cut are:
intrauterine adhesions mechanically. (a) Hysteroscopic lysis of adhesions with scissors may
use electrolyte solution as irrigation medium. Wide
1. The operating method is similar to that of TCRS. The and denuded surfaces promote the absorption of
division of adhesions is made from the central of the cav- irrigation medium due to the adhesions being close
278 E. Xia et al.
a b
c d
Fig. 9.149 Lysis of adhesions on left cornu. (a) Left cornu and uterine scopic needle electrode. (c) Scar tissues on the left wall are divided by
wall are visible under hysteroscope, with multiple cylindrical adhesions hysteroscopic needle electrode. (d) Left cornu is opened under hyster-
seen. (b) Cylindrical adhesions at left cornu are divided by hystero- oscopy, with left tubal ostium visible
to the myometrium. As a result, the probability of (c) If the scissors are not sharp enough, it would be hard
fluid overload will increase. Hence distention pres- to cut the adhesions.
sure during operation should be lower than the
mean artery pressure (MAP) to avoid fluid 9.6.4.3 Lysis of Adhesions with Fiber Optic Lasers
overload. Lysis of adhesions with fiber optic lasers is easy to manipu-
(b) It is sometimes difficult to manipulate the semi-rigid late, but may take longer time than dissection with scissors
scissors, especially when cutting the adhesions on the or resection with electrodes. Furthermore, it is too expensive
posterior walls. to be used widely.
a b
c d
Fig. 9.150 (a–c) Adhesions at right cornu are divided by hysteroscopic needle electrode. (d) Right cornu is opened under hysteroscopy, with right
tubal ostium visible
9.6.5 Intraoperative Complicated Conditions determine the direction of resections. Due to difficult pro-
and Cautions cedures, the risks of false passage or uterine perforation
during operations are increased. Therefore, monitoring
1. Patients with moderate or severe intrauterine adhesions with transabdominal ultrasonography or laparoscopy is
have badly distorted cavities and contracted uterine walls, necessary in these operations. Under ultrasound guid-
with the occlusion in cervical canal or middle/lower part ance, division of adhesions is guided along the midline of
of uterine cavity. When hysteroscopic operations are per- cervix and uterus so as to reveal the cavity by hystero-
formed in these cases, it is difficult to either distinguish scopic resectoscope. The thicknesses of uterine walls,
the anatomic structures of cervix and uterine cavity, or including fundus, anterior/posterior walls, and bilateral
280 E. Xia et al.
Fig. 9.152 Fibrous scar tissues in uterine cavity are divided by hys-
teroscopic needle electrode
Fig. 9.151 Fibrous scar tissues in uterine cavity are excised by hys-
teroscopic wire loop electrode
a b
Fig. 9.153 (a, b) Scar tissues on left lateral wall are divided longitudinally by hysteroscopic needle electrode
walls are observed with ultrasonography or laparoscopy or perforation, and the hysteroscope can easily enter into
to avoid the creation of false passage and occurrence of the false passage. Moreover, the possibility of creating a
perforation. perforation again in this situation is increased because it
2. In a patient who had a history of multiple operations in is difficult to distinguish the anatomic structure in uterine
uterine cavity, the uterus may have previous false passage cavity (Figs. 9.161 and 9.162). The procedures of hys-
a b
Fig. 9.154 (a–c) Adhesions on right lateral wall are resected by hysteroscopic wire loop electrode
teroscopic lysis of adhesions in these cases need to be the damage to normal myometrium. In general, intra-
monitored by laparoscopy or ultrasonography in order to uterine adhesions are avascular. There might be bleed-
detect the integrity of uterine serosa and the thickness of ing from small vessels when cutting approaches the
uterine walls. This can help to observe the shape of the myometrium, which can be stopped by electric coagu-
cavity and to distinguish the scar tissues from normal lation, and should be considered as a warning of stop-
endometrium or myometrium. ping resection.
3. Sometimes it is difficult to recognize the borderline 4. It is necessary to protect the normal endometrium during
between fibromuscular adhesions and uterine myome- operations, and to avoid the formation of scar tissues and
trium. Therefore we should pay attention to the depth the damage to the adjacent normal endometrium which
and the extent of incision during procedures to avoid are caused by energy sources.
282 E. Xia et al.
a b
Fig. 9.155 (a–c) Scar tissues in uterine walls are incised longitudinally along the long axis of uterus by hysteroscopic needle electrode
9.6.6 Intraoperative Monitoring 9.6.6.1 Ultrasonography

Compared to other types of hysteroscopic operations, hys-
The uterine cavity is distorted and narrowed in patients with teroscopic adhesiolysis is a procedure with a lower rate of
intrauterine adhesions, especially those with an occluded success and higher risk of complications, especially in cases
cavity. It leads to a great difficulty in operations and is prone with moderate or severe adhesions. Transabdominal ultra-
to uterine perforation, therefore intraoperative monitoring sound monitoring can be taken to increase the successful rate
with laparoscopy and ultrasonography should be conducted. and its safety. By a retrospective study, Kresowik et al. found
a b
Fig. 9.156 Lysis of adhesions in an atresia uterus. (a) A blind end and sions along midline of uterus and then a hole is visible. (c) Hysteroscopic
irregular adhesive bands are visible under hysteroscope. (b) Under wire loop electrode is used to excise the adhesions and gradually reveals
ultrasound guidance, hysteroscopic needle electrode divides the adhe- the cavity
that monitoring with transabdominal ultrasonography could 1. At the beginning of the procedure, a comprehensive scan
decrease the perforation rate of the uterus and be an ideal is taken to understand the position and size of uterus, as
method for monitoring the lysis of adhesions. well as the location of adhesions, with the help of the
Transabdominal ultrasound monitoring of hystero- images under hysteroscope (Fig. 9.163a, b).
scopic operations may guide the direction of probe or hys- 2. Under ultrasound monitoring, the wire loop is firstly put
teroscope, observe the depth of incision, monitor the in a right place, activated, and then the adhesions are
process of procedures, alert the surgeon to stop opera- excised after determining the extent of resection and
tions, and prevent occurrence of uterine perforations. being guaranteed by ultrasonography (Fig. 9.164a, b).
Thus it can greatly increase the success rate and decrease 3. During the procedures of hysteroscopy, transverse ultra-
the complications. sound scans are frequently taken to observe whether the
284 E. Xia et al.
Fig. 9.159 Laparoscopy monitors the procedure of hysteroscopic

adhesiolysis. Tubal patency test is taken and the right patent tube is
observed under laparoscope
Fig. 9.157 A normal uterine cavity is achieved by hysteroscopic 4. In cases with atresia of the uterus, the hysteroscope is
adhesiolysis
inserted through cervical canal under ultrasound guid-
ance. Transverse and longitudinal ultrasound scanning is
conducted to guide the resectoscope dividing the adhe-
sions gradually along the long axis of uterus, so that both
the cervical canal and uterine cavity are opened.
9.6.6.2 Laparoscopy
Laparoscopic monitoring is performed to inspect the pelvis,
to observe bilateral tubal patency, and to reveal the serosal
changes of uterus, as well as to find and repair any damage to
the uterus. Therefore it is an effective method of monitoring
hysteroscopic lysis of adhesions.
1. At the beginning of the operation, laparoscopy is per-

formed to explore the pelvic cavity, including observation
of the shape of the uterus and the integrity of uterine
serosa, determination of the location of the hysteroscope
and the light penetrability of uterine walls, as well as any
previous injuries (Fig. 9.168a, b).
2. During hysteroscopic procedures, the changes of the uter-
ine serosal layer should be noticed. If there are small blis-
ters, it suggests an impending perforation of the uterus and
Fig. 9.158 At the end of the procedure, the resectoscope should be the operation is to be stopped immediately (Fig. 9.169a, b).
retracted back to the level of cervical internal os and the uterine cavity
is observed 3. During hysteroscopic procedures, both laparoscopic light
transmission test and the reverse test can be taken. The
objective lens of laparoscope might be placed close to the
bright echo caused by electric resection is located in the serosal layer of uterine fundus, with the light dimmed. If
middle of uterus (Fig. 9.165). After complete removal of the light inside uterine cavity transmits across the uterine
the adhesions, the hysteroscope is retracted back to cervi- wall and can be seen under laparoscope, it indicates that
cal internal os with distention of the uterine cavity. the uterine wall of the fundus has become thin, which
Afterwards, a symmetrical uterine cavity with equal thick- warns the surgeon to stop operation there. It is named
ness of uterine walls can be observed under transverse or light transmission test (Fig. 9.170a, b). When the objec-
longitudinal ultrasound scanning (Figs. 9.166 and 9.167). tive lens of laparoscope is placed close to the serosal layer
a b
c d
Fig. 9.160 Division of adhesions by hysteroscopic scissors in a patient teroscopic scissors. (d) Uterine cavity is visible after dissection of
with atresia of the cavity. (a) A blind end is shown in cervical canal in adhesions
front of the hysteroscope. (b, c) Intrauterine adhesions are cut by hys-
of uterine fundus, and the light from hysteroscope is 4. In patients who want to get pregnant, methylene blue
dimmed, if the light from laparoscope transmits across solution can be injected into the uterine cavity at the end
the uterine wall and can be seen under hysteroscope, it of the operation so as to observe whether the tubal fimbria
indicates that the uterine wall has become thin, and is has a discharge of methylene blue solution or not via
named reverse light transmission test (Fig. 9.171a, b). laparoscopy.
286 E. Xia et al.
Fig. 9.161 A previous false passage in anterior wall of the uterus is

seen under hysteroscope
Fig. 9.162 A previous perforation is seen under hysteroscope
a b
Fig. 9.163 (a) Ultrasound scanning of the uterus. The position and size of the uterus are revealed. (b) A uterine cavity is seen under hysteroscope.
Adhesions occlude the fundus and fibrous scars are seen on uterine walls
9.6.7 Postoperative Management endometrium is fibrotic and badly damaged, the injured sur-
and Adjunctive Therapy face is difficult to heal after operation, and the risk of adhe-
sion recurrence is high. Thus, the treatment of IUA includes
Hysteroscopic adhesiolysis can divide the adhesions and not only performing hysteroscopic surgery to restore a nor-
restore a normal cavity. However, in patients with IUA, the mal uterine cavity, but also taking measures to promote the
a b
Fig. 9.164 (a) Ultrasound scanning guides the cutting direction of hysteroscopic needle electrode. (b) Intrauterine scar tissues on left uterine wall
are divided by hysteroscopic wire loop electrode
Fig. 9.165 Transverse ultrasound scanning during a hysteroscopic

procedure so as to guarantee resection in the middle of uterus
repair of endometrium and prevent the reformation of intra-

uterine adhesions, so that it can achieve the purpose of restor-
ing the normal reproductive ability of the patients. Fig. 9.166 At the end of operation, the hysteroscope is retracted back
to cervical internal os and checks the whole cavity
9.6.7.1 Hormone Treatment

Fibrosis of endometrium leads to a diminished ability of mone treatment stimulating regeneration of endometrium
endometrial regeneration. Administration of sex hormones has become a routine adjuvant therapeutic method. A com-
with suitable dosage after hysteroscopic operations can stim- mon therapy is the usage of estrogen and progesterone in a
ulate the re-growth of endometrial glands and stroma, and consecutive manner for 2 or 3 months, with estrogen 4–9
accelerate the repair of endometrium. Therefore, sex hor- mg/day for 4 weeks and the addition of progesterone in the
288 E. Xia et al.
last 2 weeks. Chang et al. reported that in cases with cyclic ulation of endometrial regeneration. Liu et al. from Beijing
hormone therapy after hysteroscopic adhesiolysis, the thick- Fuxing Hospital administrated oral estradiol valerate with a
ness of endometrium could increase more than that before dosage of 10 mg/day for 3 months, and the addition of oral
operations, but less than that in cases of control group, which medroxyprogesterone acetate in the last 5 days.
could not reach normal in thickness. Discontinuation of them resulted in withdrawal bleeding.
Cyclic hormone therapy cannot achieve a satisfied out- They found that the adjuvant administration of high-dose
come due to poor response of fibrous endometrium to hor- estrogen following hysteroscopic lysis of moderate and
mone treatment, so some gynecologists attempted to use severe adhesions could increase the recovery rate effec-
high dose and long duration of estrogen to enhance the stim- tively, and continuous usage of synthetic hormone was
superior to cyclic hormone therapy. However, it should be
noted that high-dose usage of estrogen may result in estro-
gen-related endometrial pathology. Dr. Ma in Beijing
Fuxing Hospital published a case report that a woman with
severe intrauterine adhesions developed endometrial atypi-
cal hyperplasia resulting from frequent usage of high-dose
estrogen. Myers and Hurst studied the response of endome-
trium to the administration of low-dose estrogen for a pro-
longed period, and found that, in patients with severe
intrauterine adhesions, pre- and postoperative continuous
usage of estrogen 4–6 mg/day for 4–10 weeks could achieve
some effect.
9.6.7.2 Intrauterine Placement of Barriers

Intrauterine barriers consist of mechanical barriers and bio-
chemical barriers, such as intrauterine contraceptive device,
Foley balloon catheter, Cook balloon, human amnion graft,
hyaluronic acid (HA), and seprafilm. During the healing
period of intrauterine injured surface, intrauterine barriers
keep the uterine cavity separated mechanically and prevent
Fig. 9.167 At the end of operation, longitudinal ultrasound scanning
checks the uterus and its cavity the reformation of adhesions coming from adherence of
a b
Fig. 9.168 Laparoscopy is conducted during hysteroscopic adhesioly- right posterior wall of the fundus. In addition, the left tube is swollen,
sis. (a) Under laparoscope, the uterus is in mid-position, the serosa on twisted, and wrapped by adhesions. (b) Under hysteroscope, the uterine
right fundus is adherent to omentum, and a previous dent is seen on cavity is narrowed, with extensive fibrous scars on uterine walls
a b
Fig. 9.169 Laparoscopy is done during hysteroscopic procedures. (a) which indicates a very thin uterine wall. (b) Hysteroscopy opens the
Laparoscopy is to observe the light penetrability of uterine walls. It uterine cavity, reveals the right cornua, and shows a scar area of previ-
shows a significant light penetration in right posterior walls of fundus, ous perforation
a b
Fig. 9.170 Laparoscopy is performed during hysteroscopic proce- of light in uterine wall indicates that the uterine wall in this area is thin-
dures. Place the objective lens of laparoscope close to the serosal layer ner than that in other areas. (a) Significant penetration of light in left-
of uterine fundus, dim the light, and observe the light transmission posterior wall of uterus. (b) Significant penetration of light in right
across the uterine wall. Under laparoscope, the significant penetration cornua of uterus
denuded surfaces. The combination of hormone therapy is uterine cavity during healing period of injured sur-
commonly used to accelerate the re-epithelization of the face, so that it can prevent the adherence of denuded
endometrium. surface and formation of adhesions. Frequently used
IUDs in clinic include metal loop IUDs, T-shaped
1. Intrauterine contraceptive device (IUD): IUD is often IUDs, copper-IUDs, etc. (Fig. 9.172). Lao et al.
placed into uterine cavity after hysteroscopic surgery, reported that placement of a T-shaped IUD following
and then removed 1–3 months later, which is a com- hysteroscopic resection was effective in preventing
mon adjuvant treatment of hysteroscopic lysis of adhesions formed in either uterine cavity or cervical
adhesions and always combined with cyclic hormone canal. Some scholars from abroad carried out some
therapy. IUD is a mechanical barrier, and separates the studies on which type of IUDs being the most suitable
290 E. Xia et al.
a b
Fig. 9.171 A reverse light transmission test during hysteroscopic pro- The slight penetration of light in the fundus and significant penetration
cedures. Place the objective lens of laparoscope close to the serosal of light in right cornua are seen under hysteroscope. (b) Significant
layer of uterine fundus, dim the light from hysteroscope, and observe light penetration in the fundus is seen
the light transmission across the uterine wall under hysteroscope. (a)
device used after hysteroscopic lysis of adhesions.

They concluded that metal loop IUDs should be the
best because of the large contact surface. A T-shaped
IUD has less contact surface and a copper IUD may
induce an excessive inflammatory reaction, so they
were considered inappropriate for preventing the
adhesions after hysteroscopy.
2. Intrauterine balloon: Aside from IUDs, some scholars
also adapted intrauterine use of a Foley balloon catheter
or a Cook balloon following operations on IUA to distend
the uterine cavity and prevent the recurrence of adhe-
sions. The mechanisms of action are as follows:
(a) Mechanical barrier. An intrauterine balloon which is
inflated with water can effectively keep the uterine
walls separate and act as a mechanical barrier.
(b) Intrauterine stent. Balloon acts as a stent of uterine
cavity to promote the regeneration and recovery of
endometrium along the balloon surface.
(c) Drainage. Intrauterine balloon catheter permits the
drainage of the clots and liquid out of the uterine cav-
ity to facilitate the repair of endometrium.
(d) Expansion of the cavity. The balloon inflated with
Fig. 9.172 Intrauterine placement of a T-shaped IUD following hys- water can expand the uterine cavity and divide the
teroscopic surgery (Second-look hysteroscopy on the 15th day after
hysteroscopic procedures)
residual adhesions.
The procedures of intrauterine placement of a Foley The mechanisms of human amnion on prevention of
balloon following hysteroscopic adhesiolysis are as IUA are as follows:
follows: (a) Biological barrier. Human amnion consists of five
(a) Firstly, 1 mL of a gas is injected into balloon to indi- layers, i.e., an epithelial layer, a basal layer, a com-
cate the border between the balloon and the catheter, pact layer, a fibroblast layer, and a spongy layer. It is
and then the tip of the catheter above the balloon is the thickest basement membrane in human body and
cut off with scissors (Fig. 9.173). has enough active surfaces. In addition, it was
(b) Secondly, the balloon catheter is inserted into the reported that fresh amnion might remain in the uter-
uterine cavity. ine cavity for 21 days, so it could separate the sur-
(c) The balloon is inflated with 3–5 mL sterile saline faces of uterine cavity effectively for a longer period.
solution, and does not come out when pulled gently. (b) Intrauterine stent. The basal layer of amnion contains
(d) The balloon catheter is kept in place for 1 week. both collagen fibers and reticular fibers, and is rich in
Simultaneously antibiotics are taken to prevent bioactive substances. It may act as a stent to promote
infections. migration and proliferation of surrounding normal
A Foley balloon, with its shape a sphere, is often endometrium, and therefore facilitate the repair and
adopted in uterine cavity following the treatment of IUA regeneration of endometrium. So it can prevent the
with hysteroscopy. A Cook balloon, with its shape a tri- formation of IUA.
angle, can fit the shape of a uterine cavity to a higher (c) Inhibition of inflammatory reactions. Amnion graft
degree, and therefore keep the uterine walls separate adhering firmly to the surface of the cavity can reduce
effectively. So it was recommended by some scholars. the reproduction of bacteria grown in the cavity.
3. Human amnion graft: Human amnion develops from cyto- Amnion graft, as a biological membrane, blocks the
trophoblast and has a smooth surface and a translucent bacteria passing through. In addition, it contains a
membrane without nerve, vessels, and lymph. It has been variety of protein inhibitors, and therefore inhibits
widely used in ophthalmology for ocular surface lesions, corresponding protease to produce inflammatory
burned skin and skin ulcers, and artificial vaginal recon- reactions.
struction surgeries. In 2006, Amer et al. first reported that (d) Anti-fibrosis. Amnion stroma can inhibit the prolif-
human amnion which wrapped around a balloon was eration of fibroblast and differentiation of
placed in uterine cavity following hysteroscopic adhesioly- myofibroblast, and therefore reduce the fibrosis and
sis as an adjuvant treatment for the management of IUA, the formation of scar tissues.
and achieved a good result. After that, Amer et al. in 2010 (e) The immune compatibility. Human fresh amnion is a
and Peng et al. in 2012 (from Fuxing Hospital, Capital special material with low immunogenicity, and
Medical University) reported similar studies on human induces minimal immunologic reaction when it is
amnion applied after operations of IUA to prevent recur- implanted into an alien body.
rence of adhesions and proved its safety and efficacy. The procedures of intrauterine placement of human
amnion are as follows:
(a) A human amnion graft is cut into a suitable piece,
spread on a Foley balloon with the surface of the
basement membrane facing outward, and then is
introduced into a uterine cavity (Fig. 9.174).
(b) After insertion of the balloon, it is inflated with
3–5 mL of saline solution and fixed in the cavity.
(c) The end of the catheter is connected to a drainage
bag, and the balloon is kept in place for 7 days.
(d) Oral antibiotics are given to prevent infections for
these 7 days.
4. Hyaluronic acid (HA) gel: Auto-cross-linked HA (ACP)
gel, a high concentration gel modified from a biodegrad-
able high molecular biological polymer, has significant
effects on prevention of adhesions and repair of soft tis-
sues. Intrauterine injection of ACP gel following hystero-
scopic adhesiolysis may play a similar role in mechanical
Fig. 9.173 1 mL of gas is injected into Foley balloon to indicate the
border of balloon, and then the tip of catheter above the balloon is cut prevention of the adhesions.
off with scissors
292 E. Xia et al.
9.6.8 Diagnosis and Management

Details can be seen in Chap. 12.

In all hysteroscopic surgery involving electroresection,
uterine perforation is most prone to occur in TCRA proce-
dures. In Jansen et al.’s study, the risk of complications in
TCRA was twelve times higher than that in TCRP. Uterine
perforation is the most frequent complications in TCRA. It
has been reported that the incidence of uterine perforation
was 1.1–2.7% in all cases with intrauterine adhesions, and
3.6–50% in cases with severe adhesions. Bukulmer et al. per-
formed TCRA on the patients with intrauterine adhesions
due to endometrial tuberculosis, and found that uterine per-
foration occurred in 25% of these cases. Furthermore, intra-
and postoperative bleeding is also a frequent complication in
TCRA, with the occurrence rate reported between 16.7 and
27.3%. In patients who conceive after TCRA, some compli-
cations like miscarriage, premature delivery, and placental
adhesion may also happen. In addition, recurrence of adhe-
sions in uterine cavity is easily developed after TCRA. It has
been reported that the recurrence rate of adhesions after
TCRA was 3.1–23.5%, and was 20–62.5% in severe cases. A
Fig. 9.174 Preparation of human amnion graft. The amnion graft is comprehensive scheme including hysteroscopic adhesioly-
cut into a suitable size, wraps around a Foley balloon with the basement sis, postoperative adjuvant therapy, and a second-look hys-
membrane surface facing outward, and then is inserted into uterine
cavity teroscopy in the near future is an effective means for
prevention and management.
The frequently used method is to introduce a catheter,

which is connected to a gel syringe, into uterine cavity, 9.6.9 Experiences and Evaluations of TCRA
and then push the gel into the cavity with the dose of
3–5 mL. 9.6.9.1 Success Rate of Operations
The restoration of a normal shape of the uterine cavity is
9.6.7.3 Prophylactic Antibiotics generally considered as a success of TCRA. It was reported
Routine administration of antibiotics to prevent infection is in literature that the successful restoration of normal cavity
not recommended in patients who have hysteroscopic adhe- in one procedure was at a rate of 57.8–97.5%.
siolysis. However, patients who use IUDs, Foley balloons, The central cylindrical intrauterine adhesions caused by
human amnion or ACP gel after surgery need to take antibi- adhesion between the anterior and posterior uterine walls can
otics for 3–7 days to prevent infections. be easily dissected with a high successful rate. The extensive
central adhesions are difficult to be removed, but the suc-
9.6.7.4 Second-Look Hysteroscopy cessful rate of procedures is still high. The management of
The crucial period of adhesion formations in uterine cavity marginal adhesions is more difficult. The procedures in cases
after hysteroscopic adhesiolysis is about 1–2 months post- with distorted cavities resulting from both central and mar-
operation. A second-look hysteroscopy may be taken when ginal scar tissues are complicated with a lower success rate.
the withdrawing bleeding stops after hormone treatment for The procedures in cases with uterine atresia and bilateral
2 months. The mild endometrial adhesions can be divided cornual occlusions are very complicated with the lowest suc-
mechanically by hysteroscope. Second or multiple opera- cess rate, which can be guided by ultrasonography or lapa-
tions can be performed in patients for whom moderate or roscopy. Sometimes multiple procedures are needed to
severe adhesions recur. Patients who achieve a normal cavity achieve a success. Patients who achieve normal cavities and
can try to conceive (Fig. 9.175a–c). both visible tubal ostia may have better prognosis.
a b
Fig. 9.175 Second-look hysteroscopy is performed. (a) One month IUD is in right place, and the necrotic tissues are seen in uterine cavity.
after hysteroscopic adhesiolysis. The uterine cavity is normal, and the (c) Four months after hysteroscopic adhesiolysis. Fibrous adhesive tis-
necrotic tissues are seen in the middle of the cavity. (b) One month after sues are shown on left wall of the uterus
hysteroscopic adhesiolysis. The uterine cavity is normal, a T-shaped
294 E. Xia et al.
9.6.9.2 Postoperative Menstruations patients had mild adhesions, 26 had moderate, and 10 had
Postoperative menstruation is another target for evaluating severe adhesions. There was no recurrence of adhesions after
the outcomes of hysteroscopic surgeries. However, the pro- treatment in patients with initial mild and moderate adhe-
cedure only can open a normal cavity and has little influence sions. And in ten patients with initial severe adhesions, the
on the restoration of endometrial functions. Therefore, hor- postoperative recurrence of adhesions occurred in two
mone treatment is often used to help stimulate re-growth of (20%). Yu et al. reported on the outcomes of second-look
endometrium after hysteroscopic surgery. hysteroscopy performed after TCRA in Hysteroscopy Center
It was reported that the rate of menstrual improvement of Fuxing Hospital, Capital Medical University. It was found
after hysteroscopic adhesiolysis was in the range of 52.4– that the recurrence rate of adhesions after treatment was
90.3%. Preutthipan and Linasmita reported that intrauterine 27.9% (17/61), and it was 41.9% (13/31) in patients with
adhesions with various degrees were treated by hystero- initial severe adhesions.
scopic adhesiolysis. In 44 women who had secondary amen- A repeat operative procedure, or multiple procedures,
orrhea before treatment, normal menstruation was achieved may be performed in cases with reformation of adhesions.
in 40 women (90.9%) and hypomenorrhea achieved in four The patients still can achieve satisfying outcomes even after
(9.1%). In six women who had hypomenorrhea before treat- multiple procedures. Roge reported that 148 procedures of
ment, normal menstruation was achieved in five (83.3%). adhesiolysis were performed in 102 women who had original
Donnez applied laser to the treatment of IUA and found that adhesions. Among them, four women (3.9%) had three pro-
the rate of restoration of normal menstruation was more than cedures, and five women (4.9%) had four. Capella-Allouc
80%. Roge reported that among 102 cases of intrauterine et al. reported on 31 patients who had permanent severe
adhesions, 75% of them achieved improved menstruations. adhesions and underwent hysteroscopic adhesiolysis. All of
The postoperative rate of menstrual improvement in women the patients achieved at least one tubal ostium visible after
with previous amenorrhea was 95.5%. Yu et al. published a treatment. Sixteen patients were treated with the primary
review article in 2008 to analyze 625 cases of IUA, and operation. Seven patients were cured after the second proce-
found that 528 cases of them (84.5%) achieved normal men- dure, and another seven patients were cured after three pro-
struation after lysis of adhesions. Then, a further study on cedures. There was one further patient who was treated by
infertile women with IUA who had hysteroscopic adhesioly- four procedures.
sis was carried out in Fuxing Hospital from 1998 to 2005.
Among 64 women who had initial hypomenorrhea or amen- 9.6.9.4 Postoperative Conception
orrhea, the postoperative rate of menstrual improvement was and Reproductive Outcomes
65.6% (42/64). Hysteroscopic treatment of intrauterine adhesions can
increase the pregnancy rate. Pace et al. studied on patients
9.6.9.3 Postoperative Recurrence of Adhesions with IUA and found that the pregnancy rate was 28.7%
The endometrium in cases with IUA develops fibrosis with a before treatment, and it increased to 53.6% after treatment. It
poor capacity of regeneration, and the denuded myometrial was reported in a study that in patients who had intrauterine
surfaces in uterine cavity cannot be covered by epithelium, adhesions and pregnancy loss more than twice, the live birth
so the possibility of reforming intrauterine adhesions after rate increased from 18.3% before treatment to 68.6% after
hysteroscopic procedures is quite high. Furthermore, the treatment. Yu et al. analyzed the data from literature and
recurrence of adhesions is a main obstacle to a successful reported that, in patients who had IUA and wanted to get
operation. It was reported in literature that the recurrence pregnant, the postoperative pregnancy rate was 74%
rate of adhesions following hysteroscopic adhesiolysis (468/632), which was much higher than that before opera-
ranged from 3.1 to 23.5%, which was even higher in cases tions (46%). In patients who had infertility, the postoperative
with severe adhesions (20–62.5%). pregnancy rate was 45.6% (104/228). In patients with IUA
The recurrence of adhesions is closely related to the and pregnancy failure, the postoperative pregnancy rate was
degrees of preoperative intrauterine adhesions. The more 89.6% (121/135), with the live birth rate 77.0% (104/135).
severe preoperative adhesion is, the higher postoperative Preutthipan and Linasmita reported that hysteroscopic lysis
recurrence rate will be. Pabuccu et al. studied 40 women of intrauterine adhesions was conducted in 45 women who
with recurrent pregnancy loss or infertility caused by intra- had IUA and infertility. After treatment, 16 women (35.6%)
uterine adhesions. After hysteroscopic adhesiolysis, all mini- achieved conception.
mal or moderate adhesions were divided successfully. The pregnancy rate after hysteroscopic adhesiolysis is
However, in women who had severe preoperative adhesions, closely related to the degree of IUA before operations. The
60% of them had postoperative reformation of adhesions. more serious the preoperative adhesion is, the worse the
Preutthipan and Linasmita reported that among 65 patients improvement of postoperative pregnancy rate will be. It was
who had hysteroscopic adhesiolysis, before treatment, 29 reported in literature that the pregnancy rate after hystero-
scopic operations for IUA in women with infertility was section, and one had hypogastric arteries ligation due to
between 34.9 and 62.0%, and was between 20.0 and 43.3% severe hemorrhage and placenta adhesions.
in women with severe adhesions. In a study on hysteroscopic Consequently, conceptions after hysteroscopic adhesioly-
division of adhesions reported by Valle and Sciarra, 43 sis may be considered as a high-risk pregnancy with an
women with initial mild and filmy adhesions achieved good increased risk of miscarriage and placenta pathology. Hence,
prognosis after treatment, which included 35 (81%) cases of during the whole period of pregnancy and delivery, the con-
term pregnancies. In 97 women with moderate or fibromus- ditions of placenta and uterus should be closely monitored to
cular adhesions, 64 (66%) achieved term pregnancies, while prevent the occurrence of complications.
in 47 cases with severe connective tissue adhesions, 15
(32%) achieved term pregnancies. In total, after hystero- 9.6.9.5 Factors Affecting Reproductive Prognosis
scopic treatment, the restoration of normal menstruation was After TCRA
achieved in 90% of patients, and term pregnancy was in The treatment outcomes and reproductive prognosis in
79.7%, which were much higher than that with previous patients who has IUA and infertility have always been an
blind procedures. issue of discussion by many scholars. Most specialists
Postoperative complications in women who conceive believed that the treatment outcomes and reproductive prog-
after TCRA may also occur, which include miscarriage, nosis after treatment of IUA were closely related to the types
abnormal placenta implantation, and post-delivery bleeding. and the extent of adhesions, as well as the degrees of endo-
Roge reported that 34 conceptions were obtained after treat- metrial injuries. However, the scientific data analyzing the
ment in 28 women with IUA, which included ten miscar- factors influencing reproductive outcomes following TCRA
riages and 24 live births. Baggish collected forty articles and remained insufficient. Yu et al. made a statistical analysis
discovered that, in more than 1000 patients who had intra- about the possible factors affecting reproductive prognosis
uterine adhesions, the pregnancy rate in women without following TCRA. Factors evaluated included menstrual pat-
treatment was 50%. Among them only half of conceptions tern before operations, menstrual pattern after operations,
reached full term. The pregnancy rate after hysteroscopic the degree of adhesions before operations, and the recur-
treatment was 75%, with a lower failure rate of conceptions rence of adhesions after operations. In total, 109 procedures
and fewer complications of delivery. Xu et al. reported that, of TCRA were performed in 85 women with adhesions who
in thirteen women who wished to conceive after treatment of had infertility or recurrent pregnancy loss. The mean follow-
IUA, nine pregnancies were achieved, including four term up after treatment was 3.9 ± 0.6 years, and 39 conceptions
deliveries, one placental adhesion, one placenta previa, and were achieved. In women who had amenorrhea after treat-
three spontaneous miscarriage. Yu et al. carried out a study ment, two got pregnancy (2/11 = 18.2%), and the pregnancy
on 85 women who had TCRA in Beijing Fuxing Hospital. In rate was significantly lower than those who had menstruation
total, 39 conceptions were obtained after hysteroscopic pro- after treatment (37/74 = 50%), p < 0.05. At second-look hys-
cedures, with the pregnancy rate 45.9%. Of all cases with teroscopy, the pregnancy rate in women who had recurrence
pregnancies, 25 (64.1%) got live births, five (12.8%) were of adhesions was significantly lower (2/17 = 11.8%) than
ongoing conceptions, eight (20.5%) had spontaneous mis- those who had no recurrence (26/44 = 59.1%), P < 0.05.
carriage, and one need termination of conception. Of 25 There were no significant differences of pregnancy rate after
cases with live births, five encountered placenta pathologies, treatment in women with amenorrhea, hypomenorrhea, and
including hysterectomy due to post-delivery bleeding and normal menstruation before operations (39.4%, 48.3%,
placenta implantation in two cases. There were two other 52.2%, respectively. P > 0.05). The pregnancy rates after
women who delivered low weight babies at 26–28 pregnancy treatment in women with initial mild, moderate, or severe
weeks. Capella-Allouc et al. studied on 31 patients who had adhesions were 64.7% (11/17), 53.6% (15/28), 32.5%
severe adhesions and underwent hysteroscopic lysis of adhe- (13/40), respectively, with no statistic difference (P = 0.05).
sions. Among 28 patients who had follow-ups successfully Thus it can be seen that postoperative menstrual pattern and
with a mean time of 31 months (from 2 to 84 months), 15 postoperative recurrence of adhesions are factors affecting
conceptions were obtained in 12 patients. The reproductive pregnancy rate after hysteroscopic operations. Whether the
outcomes included: 2 patients got missed miscarriage in first degree of preoperative adhesions being the factor affecting
trimester, 3 patients had pregnancy losses in second trimes- reproductive prognosis after hysteroscopic adhesiolysis or
ter, nine patients got live births, and 1 patient underwent ter- not remains to be investigated by further studies, such as
mination of pregnancy in second trimester for multiple fetal selecting more scientific classification and increasing the
abnormalities. In total, the pregnancy rate after treatment number of cases.
was 42.8% (12/28), with the live birth rate 32.1% (9/28). In Hysteroscopic lysis or removal of intrauterine adhesions
nine patients who had live births, one underwent hysterec- can restore a normal cavity, improve the menstruation and
tomy for adherent placenta during the procedure of cesarean increase the pregnancy rate. Hence it has become the most
296 E. Xia et al.
ideal method of treatment in patients with intrauterine adhe- under the circumstances that the tail string is broken,
sions. However, in spite of the wide application of hystero- blind removal is difficult, IUD embedment is suspected,
scopic operations, the postoperative recurrence of adhesions only parts of IUD are taken out, fragments of IUDs still
is still very common, and its reproductive prognosis is still remain within the uterus (Fig. 9.179), reversible fallopian
unsatisfactory. Comprehensive therapeutic measures includ- tube contraceptive device is deeply embedded in uterine
ing hysteroscopic lysis of intrauterine adhesions, placement cornua, or in women who are menopausal (the longer the
of intrauterine barriers, combination with cyclic hormone duration of menopause, the more serious the atrophy of
treatment, and regular postoperative second-look hysteros-
copy to explore and divide new-formed adhesions are the
best treatment for intrauterine adhesions.
9.7 Transcervical Removal of Uterine

Foreign Body
Enlan Xia
Transcervical removal of uterine foreign body (TCRF) is a

procedure using hysteroscopic resectoscope to remove the for-
eign bodies under direct vision. Hysteroscopy can detect and
locate accurately the foreign bodies inside the uterus. TCRF
procedure has the advantages of safe operation, high success
rate, and fewer traumas, which is the best choice for removal
of intrauterine foreign body (Figs. 9.176, 9.177, and 9.178).
9.7.1 Intrauterine Device (IUD)
1. The removal of IUD with tail string or the easy removal

of IUD can be done without hysteroscope. However, Fig. 9.177 The needle electrode is used to incise the uterine muscle
wall and the broken tip of the hook is released
Fig. 9.176 A wire loop electrode is used to remove the broken tip of a
hook embedded in the uterine muscle wall Fig. 9.178 The broken tip of the hook is taken out
Fig. 9.179 Intrauterine remnants of IUD Fragments. 1/3 of IUD has Fig. 9.180 The foreign body is held by a grasping forceps under direct
been taken out and two broken ends are embedded in the bilateral uter- vision
ine cornua
reproductive organ), the removal of IUD will be much

more difficult and prone to infection. Hysteroscopic
removal of IUD or hysteroscopic removal under ultra-
sound guidance is required for these situations.
2. The therapeutic hysteroscope is equipped with alligator
forceps, foreign body clamps, etc. which can grasp the
foreign bodies under direct vision (Figs. 9.180 and 9.181).
If it is not powerful enough, or if there is embedment, an
operative hysteroscope is needed to replace it.
3. The operative hysteroscope is fit for removal of embedded
IUD (Fig. 9.182). A wire loop electrode may be used to
hook the residual tip of IUD (Fig. 9.183), and then pull it
out (Fig. 9.184). An open semi-circular wire loop can be
put into the stainless steel ring and hook it out (Figs. 9.185,
9.186, 9.187, and 9.188). If an IUD is embedded in the
uterine wall (Figs. 9.189 and 9.190), passes through the
fibroids (Fig. 9.191), or is put around the fibroids
(Figs. 9.192, 9.193, and 9.194), the electric wire loop can
be used to incise the myometrium around the embedded
IUD or resect the fibroid (Figs. 9.195a–c, 9.196a–f, Fig. 9.181 The foreign body is pulled out by a grasping forceps
9.197a–c, and 9.198a–e), and then remove or clamp out
the IUD under ultrasound guidance. If the IUD is embed-
ded deeply, the laparoscopic examination shall be per- the 21Fr operative hysteroscope and a closed electrode
formed simultaneously to determine whether the IUD has can be used to plow deep into the uterine cornua and take
passed through the uterine serosa (Fig. 9.199) or not. it out. Sometimes, IUD may be discharged automatically
4. The spring and tail string of the reversible fallopian tube during the menstrual period due to the contraction of the
contraceptive device are often embedded in tubal ostia uterus, which the patient may not be aware of and it is still
and uterine horns. Once the tail string is broken, IUD will thought to be inside the uterus. Therefore it cannot be
be extremely difficult to remove. In such circumstances, found during the procedure of removal and its existence
298 E. Xia et al.
Fig. 9.182 The residual tip of IUD is embedded in the right anterior Fig. 9.184 The removed residual tip of IUD
wall
Fig. 9.185 The embedment of IUD in the uterine cavity

Fig. 9.183 The wire loop electrode is used to hook the residual tip of
IUD
including six cases of translocated IUD and seven cases
is also difficult to be confirmed by ultrasonography. When of absent IUD. Siegler and Kemmann reported on the
this is the case, hysteroscopic examination can be done to hysteroscopic removal of occult IUD in 10 patients, of
determine whether there is IUD or not. Valle et al. reported which two cases had a translocated device (one was bur-
that in 91 patients, IUD was removed successfully in 78 ied completely in the uterine muscle wall, and the other
cases under hysteroscopy and no IUD was observed was concealed by the amniotic cavity), and one case had
within the uterine cavity in the remaining 13 cases, the IUD moved out of the lower segment of uterus, only a
Fig. 9.188 The removed IUD

Fig. 9.186 The wire loop electrode can be put into the stainless steel
ring and the IUD is hooked out
Fig. 9.189 Embedment of IUD in the uterine myometrial layer

Fig. 9.187 The wire loop electrode can be put into the stainless steel
ring and the IUD is hooked out
by hysteroscopy under cystoscopic monitoring. An open

very small part of which can be seen by hysteroscopy and drainage catheter was placed inside the bladder for 2
was suitable to be removed by laparoscopy. In the weeks and the symptoms disappeared. There was another
Hysteroscopic Center of Fuxing Hospital, Capital case, in which only the monofilament tail of Tcu IUD was
Medical University, there was a case, in which the arm of visible under hysteroscope and IUD was misplaced in
a Tcu IUD penetrated into the bladder, causing the patient pelvic cavity and wrapped by omentum majus, which was
to suffer from micturition and hematuria. It was taken out removed by laparoscopy.
300 E. Xia et al.
Fig. 9.190 T-shaped IUD is embedded in the myometrium of uterine

fundus and lateral uterine wall Fig. 9.192 IUD is put around the base of fibroid
Fig. 9.191 Migration of IUD through the fibroids

Fig. 9.193 IUD is put around the submucous fibroid
9.7.2 Retention of Fetal Bone

tion. Verma et al. reported a case with chronic pelvic pain
The retention of fetal bone after abortion is a rare complica- resulting from the retention of fetal bones and the patient’s
tion. Fetal bone remnants may sometimes occur in a late- pelvic pain was resolved after hysteroscopic removal of fetal
term induced abortion (Fig. 9.200), which may often cause bones. Sahinoglu and Kuyumcuoglu reported that a woman
abnormal uterine bleeding, dyspareunia, and infertility. experienced persistent postmenopausal bleeding and pelvic
Elford and Claman reported that a 36-year-old woman had pain because of the residual of fetal bones after an induced
been suffering from secondary infertility for 15 years because abortion 17 years ago. Cepni et al. reported a case with a his-
of residual intrauterine fetal bones caused by induced abor- tory of 8 years of infertility, hypermenorrhea, and persistent
bones, and only a few cases can be explained by osseous

metaplasia. Clinical presentations may include abnormal
vaginal bleeding or discharge, dysmenorrhea, pelvic pain,
secondary infertility, etc. Hysterectomy or dilation and
curettage had been the usual therapeutic methods used.
Later, some cases have been treated by means of hystero-
scopic resection. Torne et al. reported on a case who had an
induced abortion at the sixth week of gestation. Four
months later she experienced dysmenorrhea, dyspareunia,
and pelvic pain. Ultrasonography revealed a strong echo-
genic band in uterine cavity and the residual fetal bones
were successfully removed with hysteroscopic resecto-
scope. They pointed out that new residual fetal bones were
feasible to be removed by hysteroscopy and were the cause
of endometrial ossification. Rodriguez and Adamson
reported a case of hysteroscopic removal of osseous meta-
plasia of the uterus. During the operation, combined exami-
nation of laparoscopy and hysteroscopy revealed bony
endometrium in the form of spicules which were perpen-
dicular to the endometrium, with most of them located in
Fig. 9.194 IUD is put around the submucous fibroid the posterior wall of the fundus. Firstly, biopsy forceps was
applied to remove the bony tissues, and then followed by
gentle curettage. Finally, a hysteroscopic resectoscope was
vaginal discharge after termination of a pregnancy. introduced into uterine cavity and then the visible remain-
Sometimes the retained fetal bones can take up most of the ing spicule bone tissues were resected and removed under
uterine cavity. HSG generally reveals no findings, but strong direct vision. Intra- and postoperative TVS was applied to
intrauterine echoes can be identified by ultrasound and the identify its existence and confirm its removal. Pathologic
retained fetal bones can be observed directly under hystero- examination of removed tissues revealed benign bony tis-
scope. The traditional management is blind curettage and sue. The patient received estrogens for 5 weeks after the
hysterectomy, which are nearly abandoned today. Letterie procedures. Afterwards, when she got pregnant, ultraso-
and Case reported a successful hysteroscopic surgery using a nography at 5–6 weeks of gestation revealed two small
resectoscope and wire loop under abdominal ultrasonogra- calcifications approximately 1 mm each. Finally, she

phy guidance for removal of retained bones caused by a achieved a live birth infant without any recurrence. Garcia
second-trimester abortion. and Kably reported a rare case of infertility caused by the
The small retained fetal bone should be differentiated osseous metaplasia of the endometrium. The preoperative
from the osseous metaplasia of the endometrium. When the ultrasonography showed a calcification in uterine cavity.
fetal bone is larger or vertical to the long axis of the uterus, a Under laparoscopic monitoring, hysteroscopic removal of
dilator should be inserted into the cervix the night before the osseous metaplasia of the endometrium was done and the
operation, and the cervix is dilated to Hegar 12 at the time of calcification was confirmed by histopathologic examina-
operation. After being located by hysteroscopy and under tion. Postoperative conception was achieved after one
ultrasound guidance, the fetal bones are clamped out by oval spontaneous menstruation cycle. It was concluded that the
forceps or taken out along with the exit of electric wire loop hysteroscopy was the first choice for treatment of endome-
(Figs. 9.201 and 9.202a–e). If it is embedded, the myometrial ossification and should be combined with laparoscopy.
trium may be incised and the fetal bone can be clamped out In 2007, Nevarez et al. from Mexico reported a rare case of
or removed. the osseous metaplasia of the endometrium. It was pointed
out that its predisposing factor was endometrial metabolic
abnormality induced by a history of uterine curettage.
9.7.3 Endometrial Ossification and Cervical Women with endometrial ossification experienced second-
Ossification ary infertility or early pregnancy loss, dysmenorrhea or
dyspareunia, with their history and ultrasonography indi-
Endometrial ossification and cervical ossification are rare cating the diagnosis. In the past, D&C and hysterectomy
conditions. Most reported cases of endometrial ossification were the choice of therapy, but now, hysteroscopy has
have a previous history of abortion and retention of fetal become a shortcut of management of this condition.
302 E. Xia et al.
a b
c d
Fig. 9.195 The residual IUD is embedded into the myometrial layer. (a, b) The surrounding myometrium is incised and IUD exposed. (c) The
wire loop electrode is used to hook IUD
In addition, chronic cervicitis may cause cervical ossifica- termination of a pregnancy. Fetal bone fragments were
tion. Cicinelli et al. reported a 41-year-old woman who had removed by curettage with a curette.
primary infertility, pelvic pain, and chronic endocervicitis.
Ossifications were developed in the upper third of the cervi-
cal canal. After pretreatment with antibiotics, the bone frag- 9.7.4 Residual Trophoblastic Remnants
ments were removed using grasping forceps under
hysteroscopy with no recurrence during 1 year of follow-up. The residual trophoblastic remnants in uterine cavity
Cepni et al. reported a case with a history of 8 years of infer- caused by missed abortion, incomplete abortion, adherent
tility, hypermenorrhea, and persistent vaginal discharge after placenta, placenta accreta, etc. can lead to intrauterine
a b
c d
Fig. 9.196 Removal of a residual IUD. (a) The residual IUD is located at the uterine fundus. (b–e) The wire loop electrode is used to hook IUD.
(f) The morphology of uterine cavity after removal of IUD
304 E. Xia et al.
e f
adhesions, amenorrhea, or irregular bleeding. If there are pletely excised from its myometrium by an electric wire
severe adhesions, the residual trophoblastic remnants may loop. Histological examination showed choriocarcinoma,
not be probed and removed completely. Hysteroscopy not which was cured by chemotherapy. Three years later, she
only can be used for diagnosis, but also for removal and got pregnancy and delivered a healthy baby girl by cesarean
resection of the trophoblastic remnants using electric wire section. Cohen et al. assessed and compared the effective-
loop under ultrasound guidance. The excised tissues can be ness of curettage of residual trophoblastic tissue between
sent for histopathologic examination (Fig. 9.203a–e). the use of hysteroscopy and conventional, nonselective and
Goldenberg et al. reported their experiences with hystero- blind procedure. In this study, 70 women were suspected of
scopic removal of residual trophoblastic tissues in 18 residual trophoblastic tissue clinically or by ultrasonogra-
patients with persistent bleeding following abortion in 16 phy after abortion or delivery, including 24 cases of tradi-
cases and delivery in two cases. All hysteroscopic proce- tional curettage and 46 cases of hysteroscopy. Persistence
dures were successfully completed with the average opera- of residual trophoblastic tissue occurred in five (20.8%)
tive time 10 min (ranging from 8 to 20 min). patients with traditional curettage and required manage-
Histopathological examination of the suspected residual ment with operative hysteroscopy. None of the patients
tissues confirmed trophoblastic remnants. After the proce- who had selective curettage under hysteroscopy needed a
dure, all cases achieved cessation of bleeding and showed second operation. None of anesthetic complications, perfo-
no residual tissues by ultrasonography. A second-look hys- ration of the uterus, fluid overload, or other surgical com-
teroscopy was performed in five patients several weeks plications occurred in patients of both groups. It was similar
later, and confirmed the absence of residuals. It was con- in reproductive outcome of both groups. It seemed that
cluded that operative hysteroscopy was an easy and short patients in hysteroscopy group tended to conceive earlier,
procedure to manage residual trophoblastic tissues, made but there was no difference in pregnancy rates. It was
positioning accurate and was superior to routine believed that hysteroscopic selective curettage of residual
D&C. There was a case of choriocarcinoma treated in the trophoblastic tissue should be preferred as an alternative
Hysteroscopy Center of Fuxing Hospital, Capital Medical procedure to nonselective, blind curettage.
University, who had induced abortion 80 days ago. Uterine
curettage did not stop the persistent vaginal bleeding after
abortion. Ultrasonography showed no abnormalities and 9.7.5 Cervical Pregnancy
blood HCG levels were on the rise. A purple blue nodule
3 mm in diameter was identified under hysteroscopy in the TCRF is applicable to the patients with dead embryo and
middle segment of anterior uterine wall, and was com- less bleeding without signs of infection. Hu et al. reported
a b
c
d
Fig. 9.197 Removal of an embedded IUD. (a) The broken tip of IUD is embedded in the myometrial layer. (b) The needle electrode is used to
incise the surface myometrium of IUD. (c) After removal of IUD, the compressing mark on IUD is seen
two cases of cervical pregnancy, which were treated suc- 9.7.6 Cesarean Scar Pregnancy
cessfully by operative hysteroscopy. The cervical canal
cannot hold irrigation fluid, leading to inadequate disten- With the rise in cesarean section rate, the cesarean scar preg-
tion, and hemostasis cannot be achieved to manage bleed- nancy increases. Embryo implantation in a scar of a previous
ing in the cavity. Therefore, excessive hemorrhage should cesarean section uterus is a rare but dangerous complication
be regarded as a contraindication of this operation (Fig. 9.205a, b), which may be associated with the poor heal-
(Fig. 9.204a–c). ing of the uterine incision and wide scar after cesarean sec-
306 E. Xia et al.
a b
c d
Fig. 9.198 Removal of an embedded IUD. (a) After incision of adhe- of uterine fundal myometrium with needle electrode, IUD is exposed.
sion at the cervical internal os, IUD is found at the uterine fundus and (d) The needle electrode is used to hook IUD. (e) A complete removal
embedded in the myometrial layer. (b) After incision of uterine fundal of metal ring
myometrium with needle electrode, IUD is exposed. (c) After incision
Fig. 9.198 (continued) Fig. 9.200 Retention of fetal bones
Fig. 9.201 The wire loop electrode is used to hook the fetal bone
Fig. 9.199 Metal ring is misplaced on the omentum majus in abdomi-
nal cavity
p regnancy. One is that the trophoblast may extend into the
myometrial layer of the uterus, the other is that the tropho-
tion. The treatment of scar pregnancy should be administered blast may develop into the uterine cavity. The latter may be
in accordance with that of ectopic pregnancy. The traditional fit for hysteroscopic operation. Transcervical resection under
surgical treatment is to undergo curettage under sufficient direct vision can be an alternative surgical treatment, the
preoperative preparations. Since the curettage procedure prognosis is good, and fertility can be preserved. Wang et al.
often causes heavy bleeding, ligation of the internal iliac reported that 11 women with cesarean scar pregnancy were
artery and even hysterectomy might have to be done. There treated in their hospital from 1999 to 2004. Cesarean scar
are two kinds of possible development of cesarean scar pregnancy was diagnosed by TVS and managed with laparo-
308 E. Xia et al.
a b
c d
Fig. 9.202 Removal of fetal bones. (a) The fetal bones are retained in the uterine cavity after induced abortion 1 year ago. (b) After removal of
the large bone, a small fetal bone is seen in the uterine cavity. (c) The uterine cavity after the removal of fetal bones. (d, e) The removed fetal bones
e of laminaria was spontaneously discharged 15 months

post-operation. Hysteroscopy was conducted and removed
about 30 fragments of laminaria.
9.7.8 Surgical Suture Threads
After cesarean section, the silk sutures may be left inside

uterine cavity (Fig. 9.206). In the past, the non-absorbable
silk suture was used at cesarean section, so the residual
thread or thread node may be seen at the internal cervical os
under hysteroscopy, and this foreign body may cause endo-
metrial bleeding or inflammation. The residual thread or
thread node may be clamped out by alligator forceps or a
wire loop electrode under the direct vision of hysteroscope.
Szlyk and Jarrett reported three cases with foreign bodies
deeply embedded in the lower urinary tract, with previous
failure in attempts of removal by standard cystoscope.
However, the 20F hysteroscope was easily introduced into
the urethra and successfully removed the foreign bodies.
Fig. 9.202 (continued) The removal of intrauterine foreign bodies requires pre-
cise positioning, and attention should be paid to preventing
scopic and/or hysteroscopic surgery, and the reproductive uterine perforation, therefore the operation should be per-
ability was preserved. The duration of gestation at the time of formed under ultrasonography and/or laparoscopic monitor-
surgeries ranged from 6 to 11 weeks. The operative proce- ing. Laparoscopic ultrasonography (LUS) is higher in
dures included laparoscopy applied in four women, hysteros- resolution than ultrasonography (Fig. 9.207a, b). Its opera-
copy in six, and hysteroscopy combined with laparoscopy in tive procedures are to first establish a pneumoperitoneum,
one, with the average blood loss 110.9 mL (range between then introduce a laparoscope, instill saline 200–300 mL into
20 and 300 mL) and average hospitalization 1.7 days (range the pelvic cavity, and then the laparoscopic ultrasonography
between 0.25 and 3 days). No complications occurred. All of probe (Sharplan probe scanning range 180°, frequency of
the patients got normal level of serum β-hCG within 4 weeks 8 mHz, 10 mm in diameter, probing depth of up to 6 cm) is
after operation. introduced under direct vision of laparoscopy via the cannula
beneath the umbilicus or at lateral side of lower abdomen
into the abdominal cavity, allowing for a free scanning of
9.7.7 Fragmented Cervical Dilator or uterus. Both the laparoscopic imaging and ultrasonography
Laminaria Tent imaging are displayed on a monitor via a mixer, which is
helpful to accurately understand the shape and the size of the
It is relatively rare. Before hysteroscopy or induced abor- uterus, and identify the extent of the lesions and the resec-
tion, a cervical dilator or laminaria tent is inserted to soften tion. For TCRF, laparoscopic ultrasonography can accurately
the cervix. However, at the time of its removal, some may locate the small lesions, discover or rule out invasive intra-
be found to be broken inside the cervical canal and migrate mural lesions and foreign bodies embedded in the uterine
into the uterine cavity, which can be positioned hystero- muscle wall.
scopically and taken out with the electric wire loop. If the
fragmented cervical dilator or laminaria is soft and fragile,
it can be sucked out with vacuum aspirator. Borgatta and 9.8 Other Hysteroscopic Operations
Barad reported on a 32-year-old nulliparous woman, a sin-
gle laminaria tent was inserted into cervical canal the day Enlan Xia
before an abortion. Before the procedure, the laminaria was
found to be tightly stuck in the cervix. Attempting to
remove it led to pushing it into the uterine cavity. On the 9.8.1 Transcervical Uterine Incision (TCUI)
third day after the abortion, another osmotic dilator was
placed to soften the cervix, and then the initial laminaria Transcervical uterine incision (TCUI) is using a hystero-
tent was crushed and removed. However, a small fragment scopic needle electrode to incise the uterine wall longitudi-
310 E. Xia et al.
a b
c d
Fig. 9.203 Removal of trophoblastic tissues. (a) Trophoblastic remnants with the formation of placenta polyps. (b, c) Electric resecting of tro-
phoblastic tissues. (d) The resected surface. (e) Postoperative morphology of uterine cavity
e 2. Postoperative hormone therapy is administered to pro-

mote the recovery of cutting surface and restoration of
menstrual cycle.
9.8.1.3 Experience and Evaluation

of the Operation
Katz et al. reported 8 infertile women (aged 27–43) with a
history of ten spontaneous miscarriages and one ectopic
pregnancy who were diagnosed as having a “T-shaped”
uterus by HSG and hysteroscopy. Hysteroscopic incision of
uterine lateral walls was performed to obtain a satisfactory
cavity. No complications occurred and a normal uterine cav-
ity was achieved in all patients. After the operation, there
were four term pregnancies achieved in 3 women, 1 ectopic
pregnancy, and no miscarriages. The authors suggested that
TCUI could be applied to correct uterine malformations such
as T-shaped uterus to improve their reproductive ability. In
2012, Xia et al. from the Hysteroscopy Center of Fuxing
Hospital, Capital Medical University first reported three
cases of TCUI for T-shaped uterus, with postoperative live
Fig. 9.203 (continued) birth achieved in all patients.
nally or using a wire loop electrode to resect the 9.8.2 Transcervical Resection for Biopsy
myometrium longitudinally so as to improve the shape of (TCRB)
the uterus and broaden the area of the cavity. After the pro-
cedure, the decrease of intrauterine pressure and the 9.8.2.1 For Diagnosis of Adenomyosis
increase of endometrial blood supply facilitate the implan- Adenomyosis is a uterine myometrial disease, and some-
tation of fertilized eggs, prevention of miscarriage, and times can be diagnosed by hysteroscopy. Keckstein reported
improvement of reproductive outcomes. This surgery is that the transcervical endomyometrial biopsy with punch
mainly applicable to narrowed uterine cavity caused by biopsy forceps or transcervical resection with wire loop
scarred uterine wall resulting from intrauterine adhesions could provide more information on adenomyosis and its
and uterine deformations with narrowed uterine cavity and depth. Endometrial and myometrial coagulation or resection
infertility. could effectively destroy or remove the superficial adeno-
myosis, but might result in iatrogenic adenomyosis, which
9.8.1.1 Indications could be managed by a repeated hysteroscopy. Incomplete
1. Patients who have intrauterine adhesions with scarred EA or TCRE might lead to adenomyosis. Therefore, symp-
uterine wall, a narrowed and small cavity, and tomatic focal adenomyosis might be treated by hysteroscopic
amenorrhea. operation in selected cases. In 1991, McCausland proposed
2. Patients who are diagnosed as T-shaped uterus, unicornu- that the hysteroscopic resectoscope could be used to resect
ate uterus or Robert uterus, and have one of following the endomyometrial strip of 2 cm in length and 3–5 mm in
conditions: depth for histopathological examination, which could be
(a) two or more spontaneous abortions used for diagnosis of adenomyosis but not suitable for those
(b) unexplained infertility who wanted to have a baby. And its accuracy needed to be
(c) primary infertility requiring assisted reproductive compared with the routine histological examination of the
technology specimens of the removed uterus. But in 2000, a review arti-
cle published by Neis and Brandner indicated that hystero-
9.8.1.2 Operative Procedures scopic resection of myometrium and histopathological
1. The procedure is to incise the uterine wall with a needle examination of resected specimen could only diagnose some
electrode or resect the thickened endometrium with a cases of adenomyosis, with the majority of adenomyosis
wire loop electrode along the long axis of the uterus. missed in diagnosis. Mercader et al. reported one case of
Generally, 4–5 incisions or resections are conducted to uterine biopsy resulting in a rare complication of vesicouter-
expand the cavity (Figs. 9.208, 9.209, and 9.210). ine fistula, which should be warned about. In 1992,
312 E. Xia et al.
a b
Fig. 9.204 Cervical pregnancy. (a) Ultrasonography. (b) Embryo sac at right bottom of the screen. (c) The removal of trophoblast by
hysteroscopy
McCausland reported the depth of adenomyosis seemed to 30% of the requirement for hysterectomy. McCausland and
be correlated with the severity of menorrhagia. Patients with McCausland’s experience was that in patients who had
superficial adenomyosis might undergo hysteroscopic endo- superficial adenomyosis with the endometrial penetration
myometrial resection. Patients with deep adenomyosis usu- <2.5 mm, hysteroscopic resection could obtain good results.
ally should be offered hysterectomy. Wood et al. conducted In patients who had deep adenomyosis with the endometrial
hysteroscopic surgery for conservative treatment of adeno- penetration >2.5 mm, hysteroscopic surgery usually leads to
myosis, including endometrial resection, myometrial elec- postoperative complications, and in this condition,
trocautery, and endomyometrial excision. Improvements of hysterectomy should be offered rather than a repeat surgery.
symptoms after treatment with different hysteroscopic sur- Neis and Brandner reported that the incidence of adenomyo-
geries were 4/7, 3/4, and 3/3, respectively, which reduced sis varied from 8 to 61% because the definitions used were
a b
Fig. 9.205 Cesarean scar pregnancy. (a) The trophoblast is invading into the uterine myometrial layer. The red line on the left represents vascular
bleeding. (b) The trophoblast is developing into the uterine cavity
in patients who experienced dysmenorrhea and had a uterus

with the length >10 cm, and should be considered as a rela-
tive contraindication of TCRE because of an increased risk
of failure.
9.8.2.2 For Diagnosis of Endometrial

Tuberculosis
Agboola et al. from UK reported that the tissue biopsy
obtained at TCRE confirmed the diagnosis of endometrial
tuberculosis for a case. This 62-year-old woman had suffered
from primary infertility and experienced unexplained meno-
pause for 30 years. She underwent hormone replacement
therapy after failure in various treatments. This time she was
admitted to hospital with breakthrough vaginal bleeding.
Hysteroscopy revealed a normal uterine cavity, and histo-
logical examination of endometrial tissues obtained by
biopsy showed benign endometrial polyps, simple endome-
trial hyperplasia, and chronic granulomatous endometritis
with surrounding lymphocytes. Thus tuberculosis was sus-
Fig. 9.206 Persistent uterine bleeding 4 months after cesarean section. pected and further investigation was suggested. In a repeat
The residual silk suture is seen under hysteroscope examination 2 months later, hysteroscopy revealed extensive
endometrial hyperplasia, which was mostly in the right uter-
different. The incidence of adenomyosis diagnosed after ine wall, and scattering endometrial scars, which were sub-
hysterectomy for unsuccessful endometrial ablation was epithelial nodules with the size <5 mm. The small nodules
between 75 and 100%. It was considered that adenomyosis were easily visible under magnifying resectoscope, and were
might be a main reason for failure of hysteroscopic surgery. resected with other endometrium for histopathological
They suggested that adenomyosis should be highly suspected examination, with the result of tuberculosis endometritis.
314 E. Xia et al.
a b
Fig. 9.207 Laparoscopic ultrasonography (LUS). The left lower figure residual fetal bones in the uterine cavity (white plaque) with acoustic
is the laparoscopic image with laparoscopic probe (black color) on the shadow on their back. (b) The arrow indicating the adhesive tissues in
anterior uterine wall. The right upper figure is the LUS image. (a) The the uterine cavity
Fig. 9.208 Narrow and cylindrical uterine cavity Fig. 9.209 The needle electrode is used to incise along the long axis of
uterus
9.8.3 Hysteroscopic Resection of Cystic

Adenomyosis is always asymptomatic in early stage, and experiences dys-
menorrhea and chronic pelvic pain in severe condition. The
Adenomyosis is developed by the invasion of ectopic glan- occurrence of cystic adenomyosis might relate to previous
dular tissues and stroma into uterine myometrial layer, form- uterine surgery. By ultrasonography examination, intramural
ing diffused or focal lesions, and is a common disorder in echolucent areas can be detected in patient with cystic ade-
women of childbearing age. Adenomyosis sometimes pres- nomyosis, which can be single or multiple cysts of variable
ents a cyst containing hemorrhagic material, which is com- size and is the basis of diagnosis. When a cystic lesion locates
monly small with the size no more than 0.5 cm. Larger cystic near the cavity, hysteroscopic operation to incise or resect
lesions are named cystic adenomyosis, with which the patient the lesion is feasible.
4. In cases with deep cysts, the endometrial-like tissues on

the surface of its base may be destroyed by coagulation
with hysteroscopic roller ball electrode (Fig. 9.212).
9.8.3.3 Experience and Evaluation

of the Operation
Laparoscopic excision is applicable in cases with cystic ade-
nomyosis approaching uterine serosa with a good therapeu-
tic effect. Hysteroscopic resection is suitable for cases with
the cyst close to the endometrium, and intraoperative ultraso-
nography guidance contributes to the positioning of the cyst.
Giana et al. published a case report and described that
hysteroscopic bipolar loop electrode was used to resect the
cystic tissues following TVS suggestion, with the histologi-
cal examination confirming the existence of typical cystic
adenomyosis. Xia et al. from the Hysteroscopy Center of
Fuxing Hospital, Capital Medical University, conducted hys-
teroscopic resection in 3 women with cystic adenomyosis. In
the first case with the lesion developed after cesarean sec-
tion, the cyst is incised by hysteroscopic monopolar elec-
Fig. 9.210 Uterine cavity after TCUI trode under ultrasonography guidance. However, the cyst
was too large (5.6 cm × 5.4 cm × 5.8 cm), which led to sub-
sequently hysterectomy. The second woman was treated by
9.8.3.1 Indications hysteroscopic resection of lesions. The wire loop electrode
The indications of hysteroscopic resection of cystic adeno- was conducted to cut open the cyst wall in left-posterior
myosis include the symptoms such as dysmenorrhea, chronic myometrium, in which the endometrial-like tissues were vis-
pelvic pain, etc., and one of following conditions: ible. The endometrial-like tissues and small cysts with the
maximum diameter 2.9 cm in them were excised one by one,
1. The cystic lesions of adenomyosis are close to the uterine and the postoperative prognosis was good. The third woman
cavity. underwent hysteroscopic adhesiolysis and incision of cysts.
2. The cystic lesions of adenomyosis do not penetrate the The myometrium of posterior wall was cut open by hystero-
whole layer of the uterine wall. scopic wire loop electrode and revealed scattered focal endo-
3. Uterine malignant lesions are excluded. metrium and ectopic lesions inside, with the largest space in
the posterior wall and 3 cm in diameter. The distance between
9.8.3.2 Operative Procedures the space and uterine serosa was less than 3 mm, which was
1. Diagnostic hysteroscope is applied firstly to observe the quite thin. Therefore, hysteroscopic coagulation on the basis
uterine cavity and investigate whether there is space- of the cyst was conducted and achieved a good outcome.
occupying lesions or not. Combined with abdominal
ultrasonography monitoring, the size and the site of the
cyst, and the distance between the cyst and the uterine 9.8.4 Transcervical Resection of Cervical
serosa can be identified (Fig. 9.211a). Lesion (TCRC)
2. Under ultrasonography guidance, hysteroscopic wire
loop electrode is used to gradually resect the endome- Cervical benign lesions, including cervical erosion, cervical
trium and the myometrium on the surface of the cyst so polypoid hyperplasia (Fig. 9.213), cervical polyps, Nabothian
that the cystic wall becomes visible (Fig. 9.211b). cyst, etc., are common and frequent diseases. Treatment
3. After the cyst is opened, effusion of brownish thickened options include cervical electrocautery, cryotherapy, laser, or
liquid can be seen (Fig. 9.211c). Endometrial-like tissues Loop Electrosurgical Excision Procedure (LEEP) for treat-
are visible on the inside surface of the cyst after drainage ment. Cervical precancerous lesion, also called Cervical
of the brownish thickened liquid (Fig. 9.211d). Then the Intraepithelial Neoplasia (CIN), is that the cervical epithelial
endometrial-like tissues and the small cysts in between cells are partly or mostly replaced by atypical cells. CIN is
are excised one by one. classified into three grades: CIN1, CIN2, and CIN3. The
316 E. Xia et al.
a b
c d
Fig. 9.211 Hysteroscopic resection of cystic adenomyosis. (a) uterus. (c) The cyst wall is cut open by hysteroscopic resectoscope, with
Examination of uterine cavity with hysteroscopy. The cystic lesion lies the outflow of brownish thickened liquid. (d) The cyst wall is resected
in left-posterior wall of the uterus. (b) Hysteroscopic wire loop elec- by hysteroscopic wire loop electrode, with the endometrial-like tissues
trode is used to resect the endometrium and sub-endometrial myome- on the inside wall of the cyst visible
trium surrounding the cyst which locates in left-posterior wall of the
treatment for CIN includes LEEP, laser conization, cold illumination of strong cold light, as well as effective
knife conization, total hysterectomy, etc. Transcervical hemostasis.
resection of cervical lesions is performed by using hystero-
scopic wire loop electrode to resect the diseased tissues of 9.8.4.1 Indications
the cervix, which can not only excise the erosion on the sur- 1. Cervical benign lesions, especially lesions in the cervical
face of the cervix, but also go deep into the cervical canal, canal, such as cervical polypoid hyperplasia, cervical pol-
inspect and remove the lesions in cervical canal under the yps, cervical erosion, cervical Nabothian cyst, etc.
the extent of resection is determined (Fig. 9.214a). In

women with CIN, 2.5% iodine tincture is used to swab
the tissues of cervix to identify the suspected areas of cer-
vical lesions.
2. The cutting usually starts from the 6 o’clock position.
The wire loop electrode is pushed out totally and placed
in the cervical canal by touching the cervical posterior
tissues gently, with the distance 0.7–0.8 cm to cervical os.
After the electricity is activated, the wire loop electrode
resects the cervical posterior tissues slowly from the
inside to the outside with an “arc” cutting, and stop at
0.1 cm outside the diseased tissues on cervical os
(Fig. 9.214b).
3. The cervical tissues are radially resected clockwise or
anticlockwise in sequence according to the extent of the
cervical lesions, with the cutting surface after resection
presenting mushroom-shape in cases with superficial
lesions and cone-shape in cases with deep lesions
(Fig. 9.214c).
4. The active bleeding on cutting surface can be stopped by
coagulating the bleeding points with wire loop electrode,
Fig. 9.212 The cyst wall in the posterior myometrium is coagulated by or by switching on the irrigation pump, detecting the
hysteroscopic roller ball electrode bleeding points on cutting surface under the irrigation of
the fluid, and then coagulating the bleeding points with
wire loop electrode (Fig. 9.215). Hemostasis can be
achieved by rollerball electrode coagulation if the cutting
surface is oozing.
5. In cases with cervical Nabothian cyst, hysteroscopic wire
loop electrode can be used to resect and destroy the cyst.
If a cyst is located deeply in the cervix, the procedure
shall be performed under ultrasound guidance; if a cyst is
large, only a part of the cyst wall can be excised to open
the cavity, and then the cyst wall can be coagulated with
a rollerball electrode or vaporized with a vaporizing elec-
trode (Fig. 9.216a, b).
6. If cervical polypoid hyperplasia or cervical polyps are
coexisting, they can be excised under the irrigation of the
fluid and direct vision (Fig. 9.217a, b).
7. All excised tissues should be sent for histological exami-
nation. In cases with CIN, the tissues should be sent sepa-
rately following multiple punch resections.
Fig. 9.213 Cervical polypoid hyperplasia 9.8.4.3 Experience and Evaluation

of the Operation
2. CIN grade 1–2 (CIN1, CIN2). 1. Prior to TCRC, cervical cytological examination and/or
3. Malignant lesions are excluded by cervical cytological biopsy histological diagnosis must be obtained. The
examination and/or histological diagnosis. range of excision during TCRC should be sufficient. The
posterior blade of vaginal speculum can be taken for sup-
9.8.4.2 Operative Procedures port of the resectoscope when cutting the anterior lip of
1. When monopolar hysteroscope is used, the cutting power the cervix. There is always no support when cutting the
is set at 60 W. Coagulating power at 40 W, and the posterior lip of the cervix.
switches of irrigating pump need not to be on. From the 2. There is still dispute about the treatment of TCRC for
beginning, the cervical lesions shall be well inspected and CIN. Clinically, it is commonly believed that TCRC can
318 E. Xia et al.
a b
Fig. 9.214 TCRC. (a) Prior to TCRC, cervical erosion and polypoid hyperplasia are visible. (b) The cervix after several cuttings during TCRC.
(c) After TCRC, the cervical surface appears to be mushroom-shaped
effectively excise lesions of CIN1 and CIN2, but is not canal, and inspect and resect the intracervical lesions with
applicable for lesions of CIN3. However, some gynecolo- wire loop electrode under the illustration of cold light.
gists have tried TCRC to treat CIN3 and achieved some The irrigation fluid can flush the cutting surface and per-
effect. mits a prompt and accurate coagulation of active bleeding
3. Comparison between TCRC and LEEP: With the limita- under direct vision, resulting in effective hemostasis.
tion of the property of the instrument, the extent of treat- Zhang Hongwei et al. reported a study that cervical
ment with LEEP is often superficial, and the treatment of lesions with CIN1 were treated by TCRC in 115 women
polypoid hyperplasia, polyps, and Nabothian cysts in cer- and by LEEP in 116 women. The results showed that
vical canal cannot usually be performed. In addition, intraoperative bleeding was significantly less in TCRC
bleeding during LEEP resection is always massive and group than that in LEEP group (P = 0.000), and the recov-
hard to be stopped, which increases the difficulty of the ery time of cutting surface was significantly shorter in
procedure. Hysteroscope can be introduced into cervical TCRC group than that in LEEP group (p = 0.021).
9.9 Other Techniques of Endometrial

Ablation
Endometrial ablation is the greatest advancement in gyne-

cological treatment at the end of the twentieth century.
However, hysteroscopic laser or high-frequency electricity
endometrial ablation requires proficient surgical skills in
hysteroscopy, and serious potential complications may occur.
In recent years, a number of non-hysteroscopic devices or
procedures for endometrial ablation have been developed,
which are also known as the second-generation endometrial
ablation. It is characterized by heating rather than direct
electrical surgery. Its superiority is simple, rapid and safe
operation with some therapeutic effects; its weak points are
that there are no specimens obtained for histological exami-
nation, the success of the procedure depends on the morphol-
ogy of uterine cavity, the space-occupying lesion requires
further management, and that the equipment cost is very
high.
Fig. 9.215 Cervical active bleeding on the cutting surface is coagu-
lated with hysteroscopic wire loop electrode for hemostasis during
TCRC
a b
Fig. 9.216 Resection of cervical Nabothian cyst. (a) The wall of cervi- cyst is displayed after the cyst wall is cut open with hysteroscopic wire
cal Nabothian cyst is cut open with hysteroscopic wire loop electrode, loop electrode
with outflow of white thickened fluid visible. (b) The base of Nabothian
320 E. Xia et al.
a b
Fig. 9.217 Resection of cervical polypoid hyperplasia tissues. (a) The resection of the polypoid hyperplasia tissues with hysteroscopic wire
polypoid hyperplasia tissues on anterior wall of the cervix are resected loop electrode
with hysteroscopic wire loop electrode. (b) The cutting surface after
9.9.1 Uterine Balloon Thermo-Ablation (UBT)
The uterine balloon thermo-ablation (UBT) is to use the

heated fluid in balloon to destroy the endometrium. The uter-
ine balloon therapeutic system is mainly comprised of a con-
troller and a balloon catheter (Fig. 9.218). The controller can
be used to control the temperature inside the balloon and
monitor continuously the pressure and treatment duration.
The balloon catheter is 16 cm in length and the balloon is
3.5 cm in long diameter. The balloon is made of latex, hous-
ing galvanic couple heater, and the other end of balloon cath-
eter is assembled with the inflow port through which the
Fig. 9.218 Controller and the balloon catheter
balloon inflating fluid can be instilled, which is also the con-
nection port to the controller. During treatment, if the pres-
sure inside the balloon is over the range of 45–200 mmHg gle intravenous anesthesia or single local nerve blocking
and the temperature inside the balloon is higher than 92 °C, anesthesia. Some published research showed that local anes-
the controller can automatically shut off the heating element thesia is better applied to patients with good tolerance during
and terminate the treatment. The patients are usually women treatment, which may diminish the complications induced by
with menorrhagia who have no desire for future pregnancies. general anesthesia. The operation should be performed
The patients may have curettage prior to operation, or receive within 3–7 days after menstruation ends. The patient is
pretreatment with danazol or GnRH analogs for a certain placed in lithotomy position and intravenous anesthesia is
period to thin the endometrium and obtain a better efficacy, administered. First, connect all the ports of the uterine bal-
but endometrial pretreatment may not be administered. The loon therapy system, empty the air inside the latex balloon
patients may take indomethacin or paracetamol preopera- until the negative pressure (−100 to −200 mmHg) is shown
tively to prevent the occurrence of postoperative uterine on the control unit. Then insert the balloon catheter through
spasm. The patients can choose general anesthesia, intrave- the cervix into the uterine cavity with the scale on the bal-
nous anesthesia plus local anesthesia, spinal anesthesia, sin- loon catheter equal to the length of uterine cavity. Then inject
the sterile 5% glucose slowly into the balloon. Heating

begins immediately when the pressure becomes stable. When
the glucose solution inside the balloon is heated up to
87 ± 5 °C, maintain this temperature for approximately 8 min
and then stop heating. When the temperature inside the bal-
loon falls to about 50 °C, pump out the liquid of the balloon
and remove the catheter, and then the treatment is completed.
Sometimes laparoscopy is performed to monitor the whole
procedure. When the uterine cavity is under thermal treat-
ment of 87 ± 5 °C and 170 mmHg, laparoscopy is used to
ensure no manifestations of enlargement, apparent expan-
sion and spasm of the uterus, no signs of congestion, hemor-
rhage or ecchymosis formation and other changes in uterine
serosa, no perforation and exudates resulting from thermal
balloon rupture, and no surrounding organs affected. After
UBT procedure, a hysteroscopy should be followed immedi-
ately and can reveal that the endometrium of the anterior,
posterior wall and uterine fundus has turned from the previ-
ous pink to pale yellow or brownish yellow, there is no flaky
congestion or hemorrhage in the endometrial surface, and no
perforation or fluid leakage. By histological examination on Fig. 9.219 Findings of uterine section
the uterine section after treatment, the endometrial layer is
seen to be edematous, and mostly deciduous; superficial 98.3%, which is similar to hysteroscopic endometrial abla-
myometrium appears to be pale white or light yellow; there tion. There are few intraoperative complications, and postop-
is a pink thermal coagulation zone with a thickness of erative complications are 3–4%, including intrauterine
3–7 mm in the submucous and superficial myometrial layer adhesions, uterine cavity stenosis, hematometra, persistent
approximately 1–2 mm away from the endometrium, the red pelvic pain, cystitis, etc.
portions above and beneath turn light red and there is no Zheng et al. from the Hysteroscopy Center of Fuxing
change in deep myometrial layer. This red thermal coagula- Hospital, Capital Medical University come to the following
tion zone is the widest in the uterine fundus and anterior and conclusions through clinical research:
posterior uterine walls, followed by the junction between the
uterine body and cervix, and the narrowest in the uterine cor- 1. There are no statistically significant differences in thera-
nua, and in some cases there is no thermal coagulation zone peutic effects of the patients’ parities and uterine
in uterine cornua (Fig. 9.219). The vaginal discharges positions.
observed after treatment are: pink vaginal discharges within 2. There are no significant differences in therapeutic effects
1–3 days; pink watery drainage within 4–7 days; and watery of the duration of treatment of 12 or 8 min.
drainage within 8–14 days, and there may be some shedding 3. The system sometimes presents a gradual decrease in the
of the necrotic mucosa. After operation, the patients may thermal balloon pressure after the start of treatment, and
develop different conditions like amenorrhea, dripping men- if the pressure is at a low level, the therapeutic effects will
ses, normal menstruation, or menorrhagia. The first three of be influenced. When the thermal balloon is at a higher
which are indicators of successful treatment, and the postop- pressure, and if there is a decline in the thermal balloon
erative amenorrhea rate is reported to be 20.6%. Gervaise pressure, a small amount of fluid may be added to the
et al. compared the success rate of UBT (73 cases) with that thermal balloon to elevate the pressure and the mean
of hysteroscopic endometrial resection (74 cases) in the pressure in the process of treatment. If the fluid is added
treatment of dysfunctional uterine bleeding. The overall suc- at the early stage of treatment, there is no significant dif-
cess rate was 83.0 ± 5% in thermal balloon group and ference in treatment temperature compared with the
76.3 ± 6% in endometrial resection group. There were no group without additional fluid, but there is significant dif-
significant differences between the two groups. The failure ference in the depth of thermal damage. Pathological
factor for the former was the retroverted uterus, and that for study has confirmed that different starting pressures taken
the latter was patient’s age less than 43 years old. They by the uterine thermal system may cause different depths
believed that uterine balloon thermo-ablation was safe, effec- of damage to the uterine wall. With the intraballoon pres-
tive, and easy to perform. There were other reports on the sure at 110–180 mmHg, the higher average pressure is,
overall effective rate of UBT procedure between 83 and the deeper the damage to the uterine wall. This result is
322 E. Xia et al.
coherent to the clinical therapeutic effects, that is, the Furthermore, UBT can lead to the changes of the endo-
higher starting pressure and final pressure within a certain metrium and uterine cavity (for example, synechiae), so it
range will entail a better clinical treatment effect. Aletebi is not suitable for women who want to retain their fertil-
et al. found that when the patients with menorrhagia were ity. Leung and Yuen reported the occurrence of
treated by UBT at the starting pressure of 80–140 mmHg, postablation-tubal sterilization syndrome following ther-
38% still experienced menorrhagia at a 1-year follow-up; mal balloon endometrial ablation.
if the starting pressure was at 140–180 mmHg, only 13%
of the patients after the treatment still experienced men-
orrhagia. The results suggested that the initial pressure of 9.9.2 Hydrothermo Ablation (HTA)
140–180 mmHg improved the therapeutic effect. With an
increase in the thermal balloon pressure from less than The principle of hydrothermo ablation (HTA) is to instill
140 mmHg to more than 140 mmHg, Vilos improved the 0.9% saline solution which is heated to 90 °C through
effective rate in patients from 52 to 89%. This indicates hysteroscope into the uterine cavity to destroy the endome-
that the higher the starting pressure, the better the thera- trium. The stimulation from the heated fluid may cause the
peutic effects, and also proves that the clinical therapeutic uterine cornua to retract, which leads to the obliteration of
effect is related to the higher starting pressure and the fallopian tubal ostia, thus the heated fluid will not flow into
final pressure. the abdominal cavity and not cause thermal damage to
4. The older the patients are, the smaller cavity the patients abdominal organs. The procedure begins with hysteroscopic
have, the severer the menorrhagia is before treatment, the diagnosis using cold saline perfusion for observation of the
better the therapeutic effects will be. Multiple regression uterine cavity. The air-insulated outer sheath of hysteroscope
analysis of the data demonstrates that only the amount of can prevent cervical canal from overheating by hot saline,
bleeding before treatment is correlated with the outcome thus the 90 °C hot saline can be injected under direct vision
after treatment. of hysteroscope and continuously flow at 45 mmHg for
5. The pretreatment by curettage prior to operation increases 10 min. In order to avoid the occurrence of thermal damage
the failure rate of treatment, and the application of GnRH caused by the entering of hot fluid into the abdominal cavity
analogs contributes to the incidence of amenorrhea and via fallopian tube, if the volume deficit between the inflow
hypomenorrhea after treatment. and outflow is greater than 10 mL, it will be detected auto-
6. At the early stage of its application, Albert conducted matically and the fluid perfusion is stopped. The thermal
UBT to treat a patient with menorrhagia who was compli- damage depth of endometrium reaches 4–5 mm, which has
cated by heart disease and achieved good results. Aletebi no damage to the basal layer, and the cervical temperature is
reported that the application of UBT in treatment of 46 42 °C at the time of operation. Guillot et al. reported that
women with high-risk menorrhagia who were compli- HTA technique was applied for treatment in 143 patients
cated with hematological disease, cardiovascular disease, with DUB and menorrhagia from six centers, with the aver-
or post-transplantation of heart or lung achieved an effec- age age of patients 48 years (37–67 years). The main com-
tive rate of 79%. Scholars in China have applied UBT to plaint of these patients was persistent menorrhagias and
the treatment of patients with menorrhagia complicated 42.4% of the patients had myomas. Intraoperative complica-
with idiopathic thrombocytopenic purpura. There are also tions developed in four cases. At follow-up with the mean
reports on the treatment of the patients who have kidney time 9 months, the postoperative satisfaction rate was 72.7%
failure, uremia, cirrhosis of the liver, transplantation of of the patients, amenorrhea achieved in 44% of the patients,
kidney, and aplastic anemia, and they all achieved good oligomenorrheic in 37% and eumenorrheic in 13%. Seven
results. Therefore the application of uterine thermal bal- patients underwent subsequently hysterectomy. Postoperative
loon system to the treatment of high-risk patients with complications occurred in 13 patients, with the majority
menorrhagia and severe medical complications can help being pelvic pain. They concluded that HTA was a simple
the patients who are unresponsive to medication and can- and effective technique for treatment of menorrhagia and
not tolerate laparotomy for treatment. This also proves could be applied for cases with uterine fibroids and irregular
that the uterine thermal system is safe, efficient, and low shaped uterus, and that HTA must be conducted under the
anesthesia-dependent, thus its application is promising. inspectation of hysteroscopy to ensure the success of the sur-
Gervaise et al. reported that 206 women with DUB were gery. Preoperative histopathological examination is compul-
treated by UBT, with three pregnancies (5.2%) achieved sory to exclude other conditions.
in 58 women post-operation, among which two experi- There was another report on 20 cases with menorrhagia
enced spontaneous miscarriage and one got placenta treated by HTA, a 12-month follow-up showed that the post-
accreta at 26 weeks. These findings suggested that bal- operative amenorrhea rate was 58%, and the operation suc-
loon ablation could not be used as a contraceptive method. cess rate was 94.5%.
9.9.3 Multi-Electrode Balloon Ablation diagnosed as complex endometrial hyperplasia with atypia
(MEBA) (CEHA) underwent MEA as a substitute for hysterectomy
because of some high-risk complications, with the frequency
The principle of multi-electrode balloon ablation (MEBA) is used at 2.45 GHz. The endometrium at the lower part of the
to apply the thermal energy coming from monopolar high- cavity near the internal orifice was preserved to prevent the
frequency current to destroy the endometrium. The device occurrence of hematometra. Histological examination of
consists of three parts, namely, the multi-electrode balloon endometrial biopsy following operation did not reveal any
guide rod at the front end, the junction part in the middle, and signs of endometrial hyperplasia. A repeat histological
the computer controller behind. There are six electrodes in examination of the endometrium 2 years later revealed the
the front of multi-electrode balloon, and six electrodes recurrence of CEHA. One month after the second MEA,
behind. The current is powered on after they are being placed MRI suggested that the endometrial line was totally replaced
in the uterine cavity (pure cutting current of 45–50 W) for by avascular area and there were no signs of endometrial
4 min with the intrauterine temperature maintained at 75 °C regeneration in uterine cavity or cervical internal os. No
as well as bilateral cornua at the same temperature. The post- recurrence was detected 18 months later.
operative amenorrhea rate achieved was 38%.
9.9.5 Bipolar Radiofrequency Endometrial

9.9.4 Microwave Endometrial Ablation (MEA) Ablation (RFEA)
The principle of microwave endometrial ablation (MEA) is Bipolar radiofrequency endometrial ablation (RFEA) is also
to use microwave energy to destroy the endometrium. The named NovaSure endometrial ablation (NovaSure), which is
equipment consists of three parts, namely, the microwave technique applying bipolar radio frequency energy with pre-
probe at the front end, the junction part in the middle, and a cise control of impedance to ablate the endometrium.
computer controller behind. The intrauterine temperature is NovaSure endometrial ablation system consists of a dispos-
displayed on the computer controller as curve line with tem- able device and a radiofrequency controller, with a radiofre-
perature maintained at 80–95 °C. Move the microwave probe quency of 500 KHz, an output power of 50 W, treatment
and let its tip make contact with each side of the uterine cav- temperature of 85 °C, and the average treatment time of 90 s.
ity. The operative time is only 2–3 min and the postoperative During operation, hysteroscopy is first used to observe the
amenorrhea rate is 57%. Tawfeek et al. reported on 35 uterine cavity and the endometrium, then the radiofrequency
women who underwent MEA either with general or local electrode is introduced into the right uterine cornu under
anesthesia between 1997 and 2005. HSGs were performed abdominal ultrasonography guidance, then the power is
intermittently 3 months later and showed that complete switched on. Ultrasonography shows the echo of the action
occlusion of uterine cavity was found in 30 women (85.7%) site strengthens gradually, and when the treatment comes to
and incomplete occlusion of tubes in five cases (14.3%). Lo an end, the controller will automatically terminate the energy
and Pickersgill reported in a literature review that the inci- delivery. The same procedure is conducted for the treatment
dence of pregnancy after endometrial ablation is 0.7%, and of the left uterine cornu → the median uterine fundus → the
there is a case report of pregnancy after MEA. Cooper et al. median of the lower segment of the uterine cavity. If the uter-
carried out a comparison of long-term outcomes following ine cavity is broader, the corresponding bilateral treatment
MEA or TCRE. At the follow-up of 5 years after operation, sites should be added. At the end of operation, when the elec-
236 cases (90%) answered the questionnaires. In two groups, trode temperature falls below 60 °C, the electrode can be
the satisfaction rates were 86% and 74%, the acceptance pulled back. Hysteroscopy is reused to observe the uterine
rates were 97% and 91%, and the recommended rates were cavity after treatment. Radiofrequency treatment has very
97% and 89%, with postoperative bleeding and pain scores small effect on the normal tissues around the targeted tissues.
significantly reduced, and the amenorrhea rates 65% and This system can display the real-time temperature, power,
69%, respectively. The hysterectomy rates were 16% and and impedance, and is also fitted with an automatic protec-
25% in MEA group and TCRE group, respectively. The tion device and will automatically terminate RF output in
results confirmed that both techniques could significantly cases of wrong connection, setting or circuit fault, over
improve the menstrual disorders and life-related quality, 110 °C temperature and more than 500 Ω impedance, etc.
with the rates of satisfaction and acceptability of treatment Therefore, it has a high safety. After comparing the second-
following MEA being higher than those following TCRE, generation endometrial ablation of radiofrequency, HTA,
which indicated that MEA might be a more effective and thermal balloon and cryoablation, scholars like Thijssen,
efficient treatment for menorrhea than TCRE. In 2005, Sabbah, and Cooper et al. concluded that the radiofrequency
Kanaoka et al. reported that a nulligravida women who was endometrial ablation is advantageous in the rates of success-
324 E. Xia et al.
ful operation, amenorrhea, and patients’ satisfaction. In symptomatic submucous fibroids, which included the safety,
2005, Baskett et al. reported on 200 cases of menorrhea who efficacy, and cost. The measures for outcomes were men-
were treated by NovaSure. At 1–4 years of follow-up with strual changes, patient satisfaction, time of back work, and
146 cases, 43.1% of the patients were amenorrheic, 41.8% use of health service within 6 months after operation. All 37
were oligomenorrheic, 4.1% were eumenorrheic, and 11% of procedures were successfully completed, with no serious
the patients still had excessive menstrual flow. Twelve (8.2%) operative complications and the mean amount of uterine
out of 146 cases required a second operation, of which ten bleeding reduced at 6 months after surgeries. Seventy-eight
cases underwent hysterectomy and two cases had a second percent of the patients achieved the improvement in bleeding
EA. One of 200 cases who was found uterine perforation on disorders, 92% of the patients were satisfied with the treat-
hysteroscopy prior to treatment underwent laparoscopy. Two ment, and no patient required a second hysteroscopic
cases were administered antibiotics for endometritis. After operation. At 6 months follow-up, the cost of treatment using
1–4 years of follow-up, 81.5% of the patients were satisfied Versapoint system was 40% cheaper than that by hysterec-
with the treatment, and 97.3% would like to recommend it. tomy or open myomectomy (£1266 vs. £2123). Therefore it
In 2007, Alperin et al. reported that a 44-year-old woman was thought that this procedure appeared to be safe, effec-
with a life-threatening uterine bleeding was diagnosed as tive, and inexpensive.
acute promyelocytic leukemia (APML) by bone marrow Recently, American Isaacson pointed out very definitely
biopsy. The control of bleeding was failed when she took that although some new devices were developed to success-
hormonal therapy or underwent uterine artery embolization fully ablate the endometrium, the strong position of hystero-
(UAE), but succeeded when NovaSure endometrial ablation scopic operation was still impregnable.
was utilized.
Suggested Reading
9.9.6 Cryo-Endometrial Ablation
An Overview of Hysteroscopic Electroresection
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Combined Hysteroscopy
and Laparoscopy 10
Enlan Xia
With the development and improvement of the endoscopic has achieved complementation of their respective advantages
techniques and surgical instruments, the minimally invasive of the two minimally invasive surgeries, allowing patients to
technique has also gained popularity in the gynecological undergo one operation with one anesthesia, which integrates
field, and more and more gynecological patients can be diagnosis and treatment as a whole and solves the previous
treated with minimally invasive techniques. Compared with problems of inability to simultaneous diagnosis and treat
open surgery, endoscopic surgery has advantages of mini- intrauterine and intra-abdominal lesions in a single setting.
mum trauma, less bleeding, less interference with organs, The dynamic combination of the two procedures will pro-
slight postoperative pain or discomfort, and quick recovery. duce positive clinical effects on the correct diagnosis of
At present, gynecological laparoscopic techniques have been gynecological diseases and the efficacy of surgical treat-
widely used in China, and the treatment of pelvic benign ment. In 2006, Kaminski et al. reported 724 endoscopic pro-
lesions by laparoscopy has shown a tendency to replace the cedures on 636 patients aged 20–41 years old, including 88
traditional open surgery. Although the development of hys- cases of combined hysteroscopy and laparoscopy, 476 cases
teroscopy comes relatively late, it has been developed very of only laparoscopy, and 72 cases of only hysteroscopy.
rapidly, and surgical indications have been continuously Compared with women with secondary infertility, women
extended. Moreover, the surgical procedures have been with primary infertility more often had tubal patency, intra-
shifted from a simple diagnosis and treatment to complex uterine malformations, and no visible findings (30%) in pel-
surgical procedures, such as hysteroscopic resection of large vis. The remaining 70% of women with primary infertility
sessile submucosal myomas and inward-protruding intramu- mostly had polycystic ovarian syndrome and endometriosis.
ral myomas; complex surgery of metroplasty, like correction The peritubal adhesions, tubal blockage, and submucosal
of uterine septum and lysis of severe intrauterine adhesions; myomas were more common in the group of secondary
hysteroscopic tubal cannulation; and gamete intra-fallopian infertility than that in the group of primary infertility. All the
transplantation transfer. Nevertheless, clinically there are detected pathologies above were treated. They concluded
still many intrauterine, intra-abdominal, and intrapelvic dis- that laparoscopy and hysteroscopy played an important role
orders requiring urgent concomitant diagnosis and treatment, in diagnosis and treatment of infertility.
such as evaluation and treatment of tubal and uterine factors
in cases of infertility, concomitant surgery for intrauterine
and intra-abdominal lesions, and the monitoring of difficult 10.1 Indications for Combined
intrauterine operations. Therefore, combined hysteroscopy Hysteroscopy and Laparoscopy
and laparoscopy will become a more effective method for
clinical diagnosis and treatment. 1. Diagnosis and treatment of infertility;
Combined hysteroscopic and laparoscopic surgery is the 2. Etiological examination and treatment of chronic pelvic
simultaneous treatment of more than two kinds of intra- pain;
abdominal and intrauterine diseases under a single anesthe- 3. Monitoring of complex hysteroscopic surgery;
sia. There have been such reports since 1990s. Compared 4. Endoscopic metroplasty for complete bicornuate uterus;
with a single type of endoscopic therapy, the joint surgery 5. Uterine artery occlusion conducted for hysteroscopic
treatment of intrauterine lesions with high risk of
bleeding;
E. Xia (*) 6. Diagnosis and treatment of space-occupying lesions in
both uterine and pelvic cavities.
Beijing, China

338 E. Xia
10.2 Contraindications for Combined retractor to spread the rectum or divide adhesive tissues, thus
Hysteroscopy and Laparoscopy the pelvic lesions are clarified. At the same time, insert the
vaginal speculum, hold and pull the cervix outward with cer-
Its contraindications include those for hysteroscopy and vical forceps. Under direct vision of laparoscope, dilate the
those for laparoscopy. cervix to Hegar 10–12. Choose 5% glucose solution as the
distention medium for monopolar surgery (diabetic patients
can choose 5% mannitol as distention medium) and 0.9%
10.3 Operative Procedures of Combined saline for bipolar surgery, set the distention pressure at
Hysteroscopy and Laparoscopy 100 mmHg and flow rate at 240–260 mL/min. Insert the hys-
teroscope and observe the endometrial thickness and intra-
10.3.1 Step 1: The Joint Examination uterine lesions in sequence from the cervical canal, the
of Hysteroscopy and Laparoscopy fundus, both fallopian tubal ostia, to anterior/posterior and
left/right uterine walls. And then, make a contrast with the
Disinfect the abdominal skin, perineum, and vagina regu- findings by laparoscopy and determine the treatment proto-
larly, place surgical drape sheets under the hips, spread asep- cols (Fig. 10.1a, b).
tic sleeves over legs, place four surgical towels in diamond
shape around the operational field over abdomen and secure
them with towel clips, cover the abdomen with large surgical 10.3.2 Step 2: Hysteroscopic Surgery Under
drape, and expose the operational field of abdomen and Laparoscopic Monitoring
perineum only. Insert a catheter and empty the bladder. Incise
longitudinally the skin below the umbilicus for approxi- Assemble the hysteroscopic resectoscope, adjust the light
mately 1.0 cm to the subcutaneous tissue. After successful source, set the output power at 80–100 W for cutting and
puncture of Veress needle, inject CO2 into the abdominal 40–60 W for coagulation of the monopolar electrode, and at
cavity and when the intra-abdominal pressure is up to 300–310 W for cutting and 90–100 W for coagulation of the
15 mmHg, pull out the Veress needle and introduce a 5 or bipolar electrode, connect and switch on the irrigating sys-
10 mm trocar and then a laparoscope. After placement of a tems, and start intrauterine operation under laparoscopic
uterine manipulator via perineum to lift the uterus, the size surveillance.
and the shape of the uterus, the appearance of ovaries and
fallopian tubes on both sides, and other lesions in pelvic cav- 10.3.2.1 Endometrial Resection
ity are detected laparoscopically. If the exposure of pelvic The wire loop electrode is used to resect the endometrium,
organ is not sufficient, add a 5 mm trocar in the left or the including the functional layer, basal layer and its underlying
right lower quadrant of abdomen, insert toothless grasper or 2–3 mm of myometrial tissues. In case of active uterine
a b
Fig. 10.1 Combined examination of a septate uterus. (a) The fundus is transversely broad with slight indentation in the middle under laparoscope.
(b) Intrauterine partial septum under hysteroscope
10 Combined Hysteroscopy and Laparoscopy 339
bleeding, a rollerball electrode may be used for coagulation point of septum and left-right alternately till the basal part
hemostasis. As for the adenomyosis tissues detected during of the septum (Fig. 10.2a, b). Note that the symmetry of
the operation, a rollerball electrode or a roller barrel elec- the operation is extremely important during surgery. The
trode can also be used to destroy the ectopic endometrium in closer to the uterine fundus, the more attention should be
superficial myometrium. paid not to damage the uterine myometrial tissues. On the
one hand, the uterine tubal ostia may serve as differential
10.3.2.2 Resection of Broad-Based Sessile markers; on the other hand, with the intervention of lapa-
Submucosal Myomas and Inward- roscopy, a close monitoring of the uterine fundus should
Protruding Intramural Myomas be performed so as to avoid uterine perforation (Fig. 10.3).
The sessile submucosal myomas or the inward-protruding When hysteroscopic operation reaches the uterine fundus,
intramural myomas all have a broad base in the muscle wall. the operation should be suspended immediately if the
It should be noted that in the cutting process the border small arterial bleeding is visible, which indicates the
between the myoma and its capsule must be identified and the resection had gone deep into the myometrium. After the
wire loop could not be used to dig into the uterine muscular septate tissues are completely resected, reduce the uterine
wall. The cutting should stop when reaching the myometrial distention pressure appropriately, examine the uterine
layer. The application of oxytocin can make the uterine wall fundus carefully, coagulate any active bleeding areas for
contraction and squeeze the tumor from myometrium to the hemostasis, and apply balloon tamponade when
uterine cavity. Most of the myoma can be excised with a small necessary.
amount of myoma tissues remaining in the myometrium,
which can develop necrosis and dissolution afterwards. Over- 10.3.2.4 Lysis of Severe Intrauterine Adhesions
resection of the myoma tissues imbedded in myometrium will Operators should be very careful when operating on exten-
cause intraoperative heavy bleeding and uterine perforation. sive adhesions with fibromuscular and connective tissues,
If the remaining myoma tissues in the uterine muscular wall especially with the high frequency electricity or laser as
grow and protrude again into the uterine cavity, a second or energy source in surgery. When the surgery is performed to
third hysteroscopic surgery may be needed. restore a normal uterine cavity, the operator should try their
best not to destroy the normal endometrium and submucous
10.3.2.3 Surgical Correction of Uterine Septum myometrial layer. When adhesions approach the uterine cor-
The surgical correction of uterine septum under hystero- nua, try to avoid deeper resection and damage to the uterine
scope should start with transverse cutting from the lowest wall so as not to cause perforation. The operation should be
a b
Fig. 10.2 (a) Resection of the septum by hysteroscopic wire loop electrode. (b) Division of the septum by hysteroscopic needle electrode
340 E. Xia
Fig. 10.4 Laparoscopic neoplasty combined with hysteroscopy for

cesarean scar diverticulum. After dividing the adhesions at lower sec-
Fig. 10.3 Hysteroscopic resection of uterine septum under laparo-
tion of the uterus under laparoscopy, hysteroscope is placed approach-
scopic monitoring. The hysteroscopic resection reaches the fundus and
ing the site of diverticulum (picture in picture), then the location of the
the light transmittance of the fundal wall is monitored laparoscopically
diverticulum and the light transmittance of the diverticulum wall are
(picture in picture)
identified laparoscopically
done under ultrasonography monitoring or laparoscopic sur- 10.3.3 Step 3: Laparoscopic Surgery
veillance, and the division should not deviate from the mid- and Hysteroscopic Surveillance
line of uterine cavity. At the end of the surgery, the objective
lens should be retracted to the internal os to observe the sym- Some laparoscopic surgery needs hysteroscopic surveillance
metry of the uterine cavity. and positioning. For example, in cases of cesarean scar
As for the complex intrauterine operations, at the time of diverticulum, hysteroscopic examination can be conducted
hysteroscopic surgery, the focal changes on uterine serosa before laparoscopy to observe its location and extent, indi-
should be observed through laparoscope. If there are small cate its position and borders, and then followed by laparo-
blisters, local pale changes, or ecchymosis, these indicate scopic neoplasty. During the operation, both light
that the active electrode is approaching the deeper parts of transmission test and reverse test should be applied by
uterine wall and that perforation is impending, hence the observing the light transmittance of diverticulum wall under
operation must be stopped. During monitoring, the light laparoscopy or hysteroscopy to determine its location
source for laparoscope may be adjusted dim to observe the (Fig. 10.4).
uterus, if bright light from the uterine cavity is visible on
any site of the uterine surface, this indicates that the part of
the uterine wall is unduly thin and the operator should be 10.3.4 Step 4: Laparoscopic Exploration
alerted to terminate the operation on this site. There are also and Surgery
scholars advocating using intra-abdominal light transmis-
sion test and intrauterine reversal test on the thickness of After the hysteroscopic operation is accomplished, the
uterine wall during hysteroscopic surgery under laparo- hysteroscopic resectoscope is removed. The uterus is
scopic monitoring. The intra-abdominal light transmission lifted again and the pelvic cavity is investigated laparo-
test is carried out as mentioned above. Regarding intrauter- scopically to see whether there is blister, hematoma, and
ine reversal test, the laparoscope is placed close to the serosa breach of the uterine serosal surface, and pale trace of tis-
of uterine fundus, and the light of hysteroscope is adjusted sue denaturation induced by the electrocoagulation, and
dim or closed. If light from the laparoscope is visible inside whether there is hematocele in the lumen of fallopian
the uterine cavity, the operation on the translucent region tubes and blood or fluid in the p elvic cavity. If uterine
should be stopped. This approach not only can suggest to perforation or active bleeding is detected, electrocoagula-
the operator the thickness of remaining uterine wall, but tion or suture for hemostasis is done under laparoscope.
also may help the operator to learn more about the insuffi- As to the other lesions in the pelvic cavity, if such opera-
ciently resected parts. tions are required like the tubal patency test with methy-
a b
Fig. 10.5 Ovarian teratoma. (a) Left ovarian teratoma under laparoscope. (b) Laparoscopic removal of ovarian teratoma
lene blue dye, ovarian cyst removal, surgeries for pelvic 10.4.1.1 Combined Hysteroscopy
endometriosis and lysis of pelvic adhesions, proper auxil- and Laparoscopy in Diagnosis
iary trocars may be added in the lower quadrant of abdo- and Treatment of Uterine
men and the corresponding laparoscopic operation is Malformations
performed (Fig. 10.5a, b). A combined examination for uterine malformations was
made in 82 cases in the Hysteroscopy Center of Fuxing
Hospital, Capital Medical University, from January 1995 to
10.4 Application of Combined September 2002. Laparoscopy was performed to observe the
Hysteroscopy and Laparoscopy fundus of the uterus and the diagnosis of septate uterus con-
firmed in 75 cases, of which incomplete septate uterus was
10.4.1 Diagnosis and Treatment of Infertility present in 71 cases and complete septate uterus in four cases
after hysteroscopic diagnosis. By laparoscopy, four cases
There are complex factors for female infertility, including were found to have bicornuate uterus, including two com-
tubal factors, uterine and cervical factors, endocrine fac- plete bicornuate uteri and two incomplete bicornuate uteri
tors, immune factors, and other factors of unknown origin. confirmed under hysteroscopy. By laparoscopy two cases
Among the factors relating to fallopian tubes, uterus and were diagnosed to have unicornuate uterus with rudimentary
cervix for infertility, the common factors include tubal atre- horns, which was diagnosed unicornuate uterus by hysteros-
sia, distortion, or adhesion; uterine and cervical myomas; copy (Table 10.1).
endometrial polyps; endometrial hyperplasia; intrauterine The treatment of uterine malformations is seen in Sect.
foreign body residues (especially retained fetal bones); 9.5 of Chap. 9. In 2002, Adolph and Gilliland reported that a
intrauterine adhesions and uterine malformation. woman who was found to have a rudimentary horn preg-
Nowadays, the combined hysteroscopy and laparoscopy is nancy underwent laparoscopic surgery. She conceived later
the optimal means to diagnose and evaluate infertility fac- and delivered a live birth infant 15 months after the surgery.
tors in the uterine cavity, fallopian tubes, and pelvic cavity They pointed out that the laparoscopic surgery had less oper-
(Fig. 10.6a, b). Hysteroscopy, characterized by its intuitive- ating time, hospitalization, and postoperative adhesions and
ness and accuracy, can be performed to resect the uterine was thus an optimal option for removal of rudimentary horn.
space-occupying lesions, divide intrauterine adhesions, and In our study, two cases of rudimentary horns did not undergo
correct the uterine malformations, thus helping patients to removal surgery due to severe bilateral tubal obliteration.
restore normal menstrual cycle and improve pregnancy and Martinez et al. conducted combined surgeries of laparos-
delivery outcomes. Therefore, hysteroscopic surgery has copy and hysteroscopy on 40 patients with Müllerian
become a standard method for treatment of uterine lesions. anomalies and infertility. The results included uterine septum
Laparoscopy combined with hysteroscopy can be per- in 23 patients (57.5%), bicornuate uterus in 6 (15%), didelphic
formed to diagnose infertility factors inside and outside the uterus in 5 (12.5%), arcuate uterus in 4 (10%), and unicornu-
uterine cavity. ate uterus in 2 (5%). Among 23 patients with uterine septum
342 E. Xia
a b
Fig. 10.6 The combined hysteroscopy and laparoscopy. (a) Laparoscopic view of pelvic tuberculosis, with calcification visible. (b) Intrauterine
adhesions under hysteroscope
Table 10.1 Combined hysteroscopy and laparoscopy for diagnosis of uterine malformations (no. of cases)
Type of malformations Hysteroscopic diagnosis Laparoscopic diagnosis Joint diagnosis
Didelphic uterus 0 – 1a
Bicornuate uterus Complete bicornuate uterus – – 2a
Incomplete bicornuate uterus – – 2
Septate uterus Complete septum 5b – 4
Incomplete septum 75c – 71
Unicornuate uterus 2 0 0
Unicornuate uterus with rudimentary horns 0 2 2a
Total 82 2 82
Notes: – indicates suspicious
a
Indicates no surgery
b
Indicates one case of didelphic uterus after combined diagnosis
c
Indicates complete bicornuate uterus present in two cases and incomplete bicornuate uterus in two cases among 4 patients after combined
diagnosis
undergoing TCRS, 13 pregnancies were achieved (56.5%), obstruction, of which 20–30% may be induced by physiolog-
including two miscarriages, four term deliveries, and seven ical spasm. Presently, it is believed that unblocking the fal-
continued pregnancies with one twin pregnancy. Pregnancies lopian tubes and treating other pelvic lesions laparoscopically
were achieved in two cases after metroplasty in four cases under direct vision is the most effective treatment method.
with bicornuate uterus. Of the arcuate uterus, the tissue pro- Previously, after laparoscopic diagnosis of proximal tubal
truding into uterine cavity was removed. Of the unicornuate occlusion, the treatment was the microsurgical removal of
uterus, one miscarriage and one term pregnancy were obtained the obliterated part and the tubal anastomosis for
following hysteroscopic surgery. It was thought that the com- reconstruction. However, by observation of the excised dis-
bined endoscopic procedures can not only precisely diagnose eased portion of fallopian tubes, the findings show that the
the uterine malformations, but also is the best method for degree of tubal fibrosis or degree of occlusion is not com-
improving fertility for women with uterine malformations. pletely in accordance with the patients’ clinical manifesta-
tions. Sulak et al. report that the tubal occlusion is caused by
10.4.1.2 Diagnosis and Treatment of Tubal the retention of the tissue debris or protein-like substances in
Infertility most cases, and hysteroscopic cannulation to unblock the
Findings of hysterosalpingography performed in infertile tubes is the preferred method of treatment. Under laparo-
patients showed that 10–20% of patients had proximal tubal scopic surveillance, the hysteroscopic cannulation can not
only relieve the tubal spasm, but also introduce the cannula on detecting pelvic factors of infertility and its influences on
directly into the interstitial section and accurately into the fertility in 324 infertile women from June 2006 to June 2009.
tubal lumen. Fallopian tube cannulation by combined hyster- The results showed that tubal disease and/or pelvic adhesion
oscopy and laparoscopy is helpful in understanding the shape were the most common reasons which account for 53.06%
of the fallopian tube, evaluating the tubal patency, and also (156/294); endometriosis was the second common reason
simultaneously diagnosing and treating other pelvic dis- with a proportion of 16.66% (49/294). For postoperative
eases, such as pelvic adhesions, endometriosis and the mini- follow-up, 30 women were lost (9.25%) and 294 women suc-
mal changes at the fimbrial end of the fallopian tube ceeded (90.75%). The conception rate following laparoscopy
(Fig. 10.7a–c). was 41.38% (123/294), including 57 pregnancies achieved in
With the improvement of equipment and technique, the 156 women with initial infertility caused by tubal diseases
curative effect of tubal cannulation is also improved. It was and/or pelvic adhesions (36.53%), 24 pregnancies in 49
reported that after treatment of tubal cannulation by com- women with initial infertility caused by endometriosis
bined hysteroscopy and laparoscopy, the patency rate was (48.97%), 17 in 29 women with PCOS (58.65%), and 13 in
70–92%. At a 12-month postoperative follow-up, the intra- 23 women with uterine myomas (56.52%). One woman got
uterine pregnancy rate was 47%, and the ectopic pregnancy pregnant by IVF after anti-tuberculosis therapy following
rate was 8%. Guo et al. from the Hysteroscopy Center of definite diagnosis by laparoscopic biopsy. One pregnancy
Fuxing Hospital, Capital Medical University, carried out a was obtained among 7 women following laparoscopic cys-
retrospective study of laparoscopic diagnosis and treatment tectomy. The conception rate was 50% in infertile women
a b
Fig. 10.7 Laparoscopic dye test. (a) Laparoscopic view of outflow of Laparoscopic view of outflow of methylene blue dye from bilateral
methylene blue dye from the right tubal fimbria. (b) Laparoscopic view tubal fimbria, indicating bilateral tubal patency
of outflow of methylene blue dye from the left tubal fimbria. (c)
344 E. Xia
with unknown reason following laparoscopic bilateral tubal to have intrauterine lesions by hysteroscopy; among 11
patency test (10/20). They held that laparoscopic examina- women diagnosed as ovarian cyst by laparoscopy, 4 women
tion can directly identify pelvic lesions and perform surger- (40%) were found to have intracervical stenosis by hysteros-
ies for treatment, and the application of laparoscopic copy. Among 118 women with the diagnosis of pelvic adhe-
technique had a significant value for diagnosis and treatment sions and 96 women with the diagnosis of both endometriosis
of infertility. and pelvic adhesions by laparoscopy, intrauterine disorders
were found by hysteroscopy in 24 cases (27%) and 26 cases
(28.0%), respectively. In eight cases without abnormal find-
10.4.2 Etiological Diagnosis and Treatment ings by laparoscopy, normal uterine cavity was found in 2 by
of Chronic Pelvic Pain hysteroscopy. It was concluded that hysteroscopy could pro-
vide intrauterine information in diagnosis of chronic pelvic
Chronic pelvic pain is one of the common gynecological pain. Therefore, laparoscopy combined with hysteroscopy in
symptoms and also a disease more difficult to diagnose clini- diagnosis and treatment of chronic pelvic pain was an effec-
cally. This disease is mostly caused by gynecological disor- tive method in improving the postoperative outcome.
ders or other factors such as genital tract infection, uterine
myomas, endometrial polyps, endometriosis, ovarian tumors,
reproductive tract abnormalities, cervical lesions, pelvic 10.4.3 Monitoring Complicated Hysteroscopic
congestion syndrome, past history of pelvic surgery, and Surgery
IUD. Due to more complex causes of chronic pelvic pain, it
is not easy to make diagnosis and the treatment will be Due to the particular structure of the uterus, the strong regen-
delayed if only traditional gynecological examination or erative ability of endometrium, the limited thickness of the
imaging diagnosis is applied. Hysteroscopic and laparo- uterine wall, the rich intramural blood supply and other fac-
scopic techniques are particularly advantageous in the diag- tors, hysteroscopic surgery is very difficult to perform, espe-
nosis of the intrauterine and pelvic lesions due to its cially procedures of reconstructive and restorative surgeries
intuitiveness and capacity of amplification (Fig. 10.8). of uterine cavity, such as lysis of severe intrauterine adhe-
Nezhat et al. studied the causes of chronic pelvic pain in 547 sions, correction of the uterine septum, and removal of ses-
patients. Among them, 48 patients who had previous hyster- sile and inward-protruding intramural myomas. It is difficult
ectomies were excluded, and hysteroscopy combined with to avoid uterine perforation during surgery. Loffer and Lewis
laparoscopy were performed in the remaining cases. The reported cases with severe bleeding caused by perforation of
results showed that, among 191 women who were diagnosed the uterus during hysteroscopic surgery. Pittrof and Wortman
as endometriosis by laparoscopy, 62 women (32.5%) were also reported on the occurrence of perforation and trauma to
found to have intrauterine abnormalities by hysteroscopy; intestine and ureter during hysteroscopic surgery. Therefore,
among 105 women diagnosed as single or multiple uterine it is necessary to monitor the hysteroscopic surgery and
myomas under laparoscopy, 46 women (43.8%) were found avoid occurrence of complications. At the initial stage of
hysteroscopic surgery, laparoscopy has already been used in
monitoring hysteroscopic surgery. In recent years, with con-
tinuous development and improvement of laparoscopic tech-
niques, its use in monitoring and adjuvant treatment in
hysteroscopy has also been well enhanced. Laparoscopic
monitoring can be performed to observe directly the changes
in the uterine serosal surface. During the process of cutting
and coagulating with the active electrode of the hystero-
scope, once there is deep cutting or coagulation of the myo-
metrial tissues and imminent uterine perforation, due to heat
conduction in local tissues, blisters may occur in uterine
serosal surface, or the transmitted light from hysteroscope is
visible under laparoscope. At this moment, the operator
should be alerted to suspend the hysteroscopic operations. At
the same time, under laparoscopy, the intestine or other adja-
cent organs can be pushed aside to avoid damage from the
hysteroscopic active electrode and its thermal conductivity.
Compared with the ultrasonography monitoring, laparo-
Fig. 10.8 Laparoscopic view of adhesions to the lateral pelvic wall scopic monitoring cannot predict the uterine perforation, but
can diagnose timely uterine perforation and detect any dam- detect timely and manage the uterine perforation so as to
age to other organs in pelvic cavity caused by perforation avoid the occurrence of serious complications, which is of
and can be used to repair the perforated organs in time. These clinical significance. Moreover, it can also diagnose and treat
advantages are superior to other methods of surveillance. the patients with concomitant pelvic lesions, which avoids
In the Hysteroscopy Center of Fuxing Hospital, Capital the trouble of rehospitalization for another operation, thus
Medical University, 165 cases underwent complex intrauter- reducing the patients’ pains and economic burden.
ine operations under laparoscopic monitoring, which
included 29 cases of TCRA due to intrauterine adhesions
involving more than 1/3 of the uterine cavity or muscular 10.4.4 Metroplasty for Complete Bicornuate
adhesions in both cornua; 52 cases of TCRS; 16 cases of Uterus
TCRF with the fetal bone residues and IUD fragments
embedded in the uterine wall removed; 68 cases of TCRM Under laparoscopic monitoring, hysteroscopic wire loop
with multiple or >4.5 cm submucosal myomas resected. electrode or needle electrode is used to incise transversely on
During the surgery, incomplete uterine perforations occurred the intrauterine plate and the fundus of bicornuate uterus,
in six cases and uterine perforations in three cases. The causing artificial perforation. Then extend the incision to
incomplete uterine perforations occurred in four cases of bilateral uterine cornua, and the full layer of the uterine inci-
TCRM (three cases of myomas greater than 4.5 cm in diam- sion wall is sutured longitudinally by laparoscopy (Figs. 10.9,
eter, one case of multiple submucous and inward-protruding 10.10a–f, and 10.11a–f).
intramural myomas), one case of TCRA, and one case of
TCRS, in which the uterine serosal surface appeared to be
locally pale white with blister and ecchymosis under laparo- 10.4.5 Laparoscopic Uterine Artery Ligation
scope. Uterine perforation occurred in two cases of TCRA and Hysteroscopic Surgery
and one case of TCRM, in which a break in the uterine sero- for Intrauterine Lesions with High Risk
sal surface was visible under laparoscope, and active bleed- of Hemorrhage
ing as well. Of two cases of TCRA, one case had uterine
perforation in the anterior uterine wall with the diameter The risk factors for uterine bleeding in hysteroscopic surgery
about 0.6 cm accompanied with active bleeding, and laparo- include uterine perforation, placenta accreta, cervical preg-
scopic electrocoagulation was performed for hemostasis nancy, cesarean scar pregnancy, uterine arteriovenous fistula,
immediately. The other case had perforation in the lower seg- and coagulation disorders. As early as 1999, Perrotin et al.
ment of posterior uterine wall measuring about 1.5 cm and applied uterine artery ligation to facilitate the surgery for
laparoscopic suturing was done to stop bleeding. The above uterine malformation. In 2000, Liu reported that laparo-
uterine perforations occurred during the resection of larger scopic bipolar coagulation was performed to occlude uterine
submucosal myomas, lysis of severe intrauterine adhesions, arteries and anastomoses between the ovarian and uterine
and opening occluded uterine cavities. The severely dam- arteries in three women with symptomatic myomas. All
aged endometrium and deformed uterine cavity, as well as
the lost direction of uterine axis, coupled with electrosurgi-
cal procedures, all contributed to the active electrode to pen-
etrate the uterine wall, causing perforation. Direct
visualization of the changes in the uterine serosal surface
under laparoscope solves the problem that ultrasonography
monitoring can only suggest but not manage the uterine per-
foration. At the same time, the intestine or other adjacent
organs may be pushed aside under laparoscopy to avoid
damage from the hysteroscopic active electrode and its ther-
mal conductivity. The six cases of incomplete uterine perfo-
rations mentioned above are all detected by laparoscopy and
the hysteroscopic operations were timely terminated, thus
avoiding the occurrence of serious complications. Those
three cases of uterine perforation are also treated timely by
laparoscopy, which eliminate the laparotomy, thus reducing
the risk of hysteroscopic complications to a minimum.
The implementation of laparoscopic monitoring in the
highly difficult intrauterine surgical procedures can not only Fig. 10.9 The fundus of bicornuate uterus (prior to metroplasty)
346 E. Xia
a b
c d
Fig. 10.10 Metroplasty for complete bicornuate uterus. (a) Transverse foration which approaches the left cornu. (d) Transverse incision of
incision of uterine fundus with hysteroscopic needle electrode. (b) uterine fundus with needle electrode and perforation is impending. (e)
Transverse incision of uterine fundus with needle electrode to cause Transverse incision of uterine fundus with needle electrode and perfo-
artificial perforation which approaches the right cornu. (c) Transverse ration occurs. (f) Transverse incision of uterine fundus with needle elec-
incision of uterine fundus with needle electrode to cause artificial per- trode and communication between uterine cavity and abdominal cavity
e f
women had improvement in menorrhagia and dysmenorrhea 10.4.6 Diagnosis and Treatment
symptoms and progressive reduction in size of the uterus and of the Coexistent Pelvic
the dominant myoma. Since then, there have been a lot of and Intrauterine Lesions
reports on the application of this technique in the treatment
of dysfunctional uterine bleeding, uterine myomas, adeno- The development of gynecological endoscopic techniques
myosis, or laparoscopic removal of myomas, subtotal hyster- prompts the two minimally invasive surgeries of hysteros-
ectomy, and total hysterectomy. It is not technically difficult copy and laparoscopy combined into clinical use. Any intra-
to occlude the uterine arteries under laparoscopy on the basis uterine lesions concomitant with pelvic disorders can
of traditional open surgery. Moreover, there were reports on undergo combined hysteroscopic and laparoscopic exami-
the occlusion of the uterine vessels using titanium clip, coag- nation and (or) surgery (Figs. 10.13 and 10.14). In
ulation, suture, ligature, and other various methods, which Hysteroscopy Center of Fuxing Hospital, Capital Medical
could achieve the similar effect, and no complications University, 275 patients underwent hysteroscopy, with dif-
occurred. It has been used in the treatment of uterine arterio- ferent types of surgeries in conjunction with laparoscopic
venous fistula and auxiliary treatment of cervical pregnancy diagnosis and intraoperative monitoring. Among them, 108
with methotrexate. They all indicated that, for hysteroscopic patients underwent laparoscopic diagnosis and monitoring;
surgeries in patients with high risk factors of hemorrhage, 167 underwent one to three types of laparoscopic treatment,
the combined laparoscopy of prophylactic uterine artery and 17 received four or more types of surgeries (Table 10.2).
ligation was feasible and effective. The methods of uterine Following the operations, two cases had acute urinary tract
artery ligation are shown in Fig. 10.12a–c. infection, one case had upper respiratory tract infection, one
348 E. Xia
a b
c d
e f
Fig. 10.11 Metroplasty for complete bicornuate uterus. (a) The inci- roscopy. (e) The fourth longitudinal suture under laparoscopy. (f) The
sion of uterine fundus is extended under laparoscopy. (b) The first lon- fifth longitudinal suture under laparoscopy and the fundal reconstruc-
gitudinal suture of uterus under laparoscopy. (c) The second longitudinal tion completed
suture under laparoscopy. (d) The third longitudinal suture under lapa-
a b
Fig. 10.12 (a) Isolation of uterine artery at its origin. The upper The left uterine artery is isolated from opened posterior leaf of the
clamped artery is the trunk of left uterine artery. The tubular tissue on broad ligament over left uterosacral ligament. (c) Anterior isolation of
its left is the obliterated left superior vesical artery, and the tubular tis- ascending uterine artery. The lower clamped artery is the left ascending
sue on its right is the left ureter. (b) Posterior isolation of uterine artery. branch of uterine artery
Fig. 10.13 Uterine myoma combined with ovarian cysts Fig. 10.14 Uterine submucous myomas combined with an omental
tumor
350
Table 10.2 275 cases of combined hysteroscopy and laparoscopy (cases)

Laparoscopy EMS
Cytoreductive Ovarian Polycystic ovarian Lysis of Unilateral Excision of
Hysteroscopy surgery Cystectomy cystectomy drilling adhesions Salpingostomy Myomectomy Hydrotubation salpingectomy adnexa
TCRS 77 7 1 5 2 10 1 2 20 0 0
TCRA 33 6 1 4 1 8 1 2 13 0 0
TCRM 70 6 2 4 0 12 0 14 5 1 0
TCRE 43 11 3 23 1 6 0 9 0 2 1
TCRF 18 2 1 0 0 5 0 0 3 0 1
TCRP 29 9 4 4 3 4 1 1 8 0 1
No surgery 5 0 0 0 0 1 0 0 0 0 0
Total 275 40 12 40 7 45 3 28 49 3 3
Note: Each case may undergo laparoscopic treatment of multiple lesions
E. Xia
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Ultrasonography Monitoring During
Hysteroscopic Surgery 11
Dan Zhang
Operative hysteroscopy is a surgical procedure implemented tion of the uterine corpus needs to be visualized. During hys-
using hysteroscopic resectoscope, which belongs to intra- teroscopy, a cervical forceps is used to pull the cervix
uterine gynecology and includes TCRE, TCRM, TCRS, outwards to expose the uterine fundus, so that it will not
TCRA, and TCRF using wire loop electrode, and EA using affect the surgeon’s operation due to the overfilled bladder.
rollerball electrode. For those who have a history of pelvic surgeries, if there are
Two-dimensional (2D) ultrasonography is done by scan- pelvic adhesions, when the cervical forceps is pulled out-
ning the uterus longitudinally and transversely to visualize wards, the movability of the uterus will be small. Therefore,
the contour of uterus, the echoes of uterine wall, and the there will be a slightly more amount of filling fluid in the
shape of uterine cavity, as well as measuring various lines of bladder than those with no pelvic surgery, which makes it
the cavity, the wall, the outline, and the cervix. It can diag- appropriate to expose the uterine fundus.
nose most of uterine abnormalities and has been a routine On ultrasonography, the probe entering the uterine cavity
method of examination to screen for occupying lesions and can be observed, and the direction of the probe reaching the
morphological abnormalities. fundus is determined. Under ultrasonography guidance, the
Transabdominal ultrasonography is one of the methods in hysteroscope is introduced into the cervical canal to internal
guiding hysteroscopic surgery. Through observation of the os (Fig. 11.1), and the distention medium is irrigated into the
intrauterine procedures on 2D imaging and guidance for uterine cavity. The distention medium injected into the uter-
complex surgical process, the occurrence of complications ine cavity and the fillings in bladder form acoustic windows
can be reduced and the surgical safety can be improved. By for double contrast (Fig. 11.2).
observation of two contrasted acoustic windows formed by From the beginning of surgery to end, the two-dimensional
fluid-distension uterine cavity and fluid-filled bladder, ultra- double-contrast ultrasonography imaging is performed to
sonography scan can clearly visualize the contour of uterus continuously monitor the surgical process. The following
and the shape of cavity, display the location and the condi- contents should be included in observation.
tion of intrauterine operating instrument in real-time, indi-
cate the extent and the depth of the incision, and timely
suggest for the operator to terminate the operation so as to
avoid uterine perforation, ensure successful procedures, and
guarantee the operational safety.
11.1 Techniques of Ultrasonography

Guidance
The patient is placed in bladder lithotomy position. The blad-

der is filled, and its amount varies from person to person. For
those who have no history of pelvic surgery, the upper sec-
D. Zhang (*)
Department of Ultrasound, Fuxing Hospital, Capital Medical
University, Beijing, China Fig. 11.1 Under ultrasonography guidance, the hysteroscope is intro-
e-mail: dan.zhang@263.net duced into the cervical canal to internal os

354 D. Zhang
Fig. 11.2 The distention medium injected into the uterine cavity and
the fillings in bladder form acoustic windows for double contrast Fig. 11.3 The lining of uterus after resection appears to be strong
echogenic band of 3–4 mm in width
1. To observe the changes in the thickness of uterine wall

and the location of resectoscope in order to prevent uter- myometrium, the strong echogenic band may fade away after
ine perforation. 15–40 min of resection. When the cutting depth is confined
2. To identify the signs that suggest changes in the echoes to the endometrial layer, the strong echogenic band formed
under the electrical thermal effects on the inner uterine may disappear rapidly. During operation, after the uterus
lining and the muscle wall so as to determine the depth shrinks due to the electrical resection, the effect of uterine
and extent of resection and intramural lesions. distension is poor, the inner lining of uterus may become
3. To determine the location and the size of the intrauterine ruffled, leading to missed resection. The important indica-
lesions, the relationship between the intrauterine lesions tion for preventing missed resection is the strong echogenic
and the uterine cavity, and to monitor the resection of band being intact by ultrasonography. The duration of the
intrauterine and intramural lesions. strong echogenic band is an ultrasonic indication suggesting
4. To explore whether there are uterine malformations and the cutting depth. The location of resectoscope can be closely
old injuries which are difficult to diagnose or not and monitored to prevent the wire loop from pushing tight against
make further diagnosis. or penetrating the uterine wall. When the outer edge of the
5. To observe the effect of intraoperative medication. strong echogenic band reaches the deep myometrium, it sug-
6. To observe intrauterine distending pressure: Whether gests that the operator should stop the cutting on this site,
there is irrigation fluid flowing via the fallopian tubal which may prevent uterine perforation effectively.
ostia into abdominal cavity or not, and how much has
flown into the abdominal cavity.
11.2.2 Ultrasonography Guidance
for Endometrial Ablation
11.2 Ultrasonography Guidance
for Intraoperative Operation Endometrial ablation (EA) is a procedure performed by roll-
erball electrode of hysteroscope to destroy endometrium in
11.2.1 Ultrasonography Guidance for TCRE order to achieve the purpose of reducing menses and treat the
dysfunctional uterine bleeding. During EA, when the roller-
Transcervical resection of endometrium (TCRE) is a proce- ball electrode is used to destroy the endometrium, the lining
dure to resect the endometrial functional layer, the basal of uterus may dehydrate and shrink due to the electric ther-
layer, and underlying 2–3 mm myometrial layer with the mal effect and form a strong echogenic band similar to
hysteroscopic wire loop, so as to reduce the menstrual flow, TCRE. However, the strong echogenic band formed after EA
relieve dysmenorrhea, and achieve the purpose of artificial may disappear quickly and the duration time is approxi-
menopause. The resected uterine wall may dehydrate and mately 5 min. Since the thermal effect of the rollerball elec-
shrink due to heat produced by the high-frequency thermal trode is enhanced with a prolonged coagulation and is
effect of the wire loop during surgery. The linear echoes in decreased with an increased power, too long local coagula-
the inner lining of the uterus turn into strong echogenic band tion can cause too deep electric thermal damage to the uter-
of 3–4 mm in breadth (Fig. 11.3). When the cutting reaches ine wall when the power is constant, which is the main cause
11 Ultrasonography Monitoring During Hysteroscopic Surgery 355
of uterine perforation during EA. During the operation, when operation should start with the lower edge of the tumor or
the strong echo developing at the uterine wall reaches the one side. During the operation, ultrasonography should sug-
deep myometrium and approaches the serosal layer, this is an gest the location of endoscope and the direction of resection
important indication to stop local coagulation. Compared and guide the operator to cut the myoma thinner or into
with that of TCRE, the indications for ultrasonography guid- oblate spheroid shape so that it can be clamped with oval
ance during EA are observation of the depth of strong echo forceps and screwed out. Larger myomas tend to need mul-
developed in the lining of uterus, rather than the duration of tiple cutting and clamping before complete removal.
the strong echogenic band. Intraoperative ultrasonography shows that the resected sur-
face appears to be with strong echogenicity (Fig. 11.5). After
surgery, myomas are totally removed, the uterine cavity is
11.2.3 Ultrasonography Guidance for TCRM empty, and the resected surface appears to be with strong
echogenicity (Fig. 11.6).
Transcervical resection of myoma (TCRM) includes trans- Since 1/2 to 2/3 of an uterine inward-protruding intramu-
cervical resection of submucous myoma and transcervical ral myoma lies in the uterine wall, the normal myometrium
resection of inward-protruding intramural myoma. outside the tumor is squeezed thin and the 1/3 to 1/2 of the
Submucous myomas are classified into three types, myoma protrudes into the uterine cavity (Fig. 11.7). Under
namely submucous myoma with a narrow pedicle, submu-
cous myoma with a broad pedicle, and sessile submucous
myoma. During the growth of the submucous myoma with a
narrow pedicle (Fig. 11.4), the pedicle may grow long and
narrow with the enlargement of the tumor. The tumor inside
the uterine cavity may elicit foreign-body-like stimulation to
the uterus, causing uterine contraction and prompting the
tumor to prolapse into the cervical canal or vagina with its
pedicle remaining in the uterine cavity. Sometimes it can be
concomitant with the introversion of uterine wall at the site
of tumor pedicle. During the operation, the role of the ultra-
sonography is to suggest the depth of resection on pedicle
and is to guide the surgeon in cutting at the edge of pedicle
so as to avoid damage to the introverted uterine wall. As for
submucous myoma with a broad pedicle or without a pedi-
cle, the location of its base should be first determined. If the
base is lower and the tumor is <3.0 cm in diameter, the oper- Fig. 11.5 During operation, the narrow pedicle submucous fibroid in
ator may start resection from its base under ultrasonography the anterior wall is partly resected, and the resected surface appears to
be with strong echoes
guidance. If the base of the myoma is in upper portion of
cavity, or the cavity is fully filled by a large myoma, the
Fig. 11.6 After operation, the narrow pedicle submucous fibroid in the
Fig. 11.4 The narrow pedicle submucous fibroid in the anterior wall is anterior wall is totally resected, and the resected surface appears to be
visible before operation with strong echoes
356 D. Zhang
Fig. 11.7 Inward-protruding intramural myoma before resection Fig. 11.8 An arc-shaped strong echogenic band between the myoma
and the myometrial wall is formed during operation
ultrasonography monitoring, the resection of myoma is firstly

performed till parallel to the lining of the uterus. At this
moment, intraoperative ultrasonography scan may reveal, due
to the uterine contraction induced by cutting with electric
wire loop, the myoma within the uterine wall is squeezed into
the uterine cavity. Then, the extruded uterine wall at the outer
edge of the myoma may gradually restore, the border between
the myoma and the uterine wall becomes clear, and the intra-
mural myoma is protruding gradually into the uterine cavity,
which suggest that the operator may continue cutting and
clamping the myoma. The repeated cutting and clamping
may isolate the myoma gradually from the normal myome-
trial wall. The irrigation fluid and the gas produced from
vaporization may infiltrate into the tissue between the myoma
and the myometrial wall, where an arc-shaped strong echo-
genic band is formed (Fig. 11.8). This sign indicates that the Fig. 11.9 After operation, the uterine cavity is empty and the resected
surface appears to be with strong echogenicity
myoma may be all squeezed into the uterine cavity and
removed by a hysteroscopic resection. If the contraction of
the uterus is poor, the sonography will find that the intramural myomas is 30 IU. After the total removal of the myoma, ultra-
myoma cannot be squeezed into the uterine cavity, in that sonography shows that the myoma bed and the surrounding
case intravenous injection of oxytocin 10 IU should be given normal uterine wall are almost parallel or concaved. After
so as to promote uterine contraction. After intravenous injec- repeated intravenous injection of oxytocin, if the residual
tion of oxytocin, the focus of ultrasonography monitoring is myoma in the uterine wall has not been squeezed into the
to observe whether there is arc-shaped strong echogenic band uterine cavity or isolated from the uterine wall, it indicates
between the residual myoma and the uterine wall or not, that the myoma cannot be removed at one time, and a second
whether the myoma moves gradually towards the uterine cav- surgery may be required. After total removal of intramural
ity and whether the extruded uterine wall thickens gradually. fibroids, the uterine cavity is empty and the resected surface
The extrusion of the intramural myoma and the recovery of appears to show strong echogenicity (Fig. 11.9).
the squeezed uterine wall are completed along with the pro- For initial cases, the removal of myomas is always con-
cess of the surgery, so the ultrasonography guidance has to comitant with the resection of endometrium. Recent studies
provide continuously the information about the resection of have found that patients with submucous or inward-protruding
myoma and the restoration of the uterus so as to ensure a intramural fibroids usually have an expanded uterine cavity
smooth operation. If contraction of the uterus after intrave- and thin uterine wall. Therefore, the resection of endome-
nous injection of oxytocin is not obvious, oxytocin can be trium after the removal of fibroids can easily cause uterine
used repeatedly. The maximum amount of application of oxy- perforation. Patho-anatomically, the uterine submucous
tocin by the author in monitoring transcervical resection of myoma and inward-protruding intramural fibroids may
increase the endometrial line, which is one of the causes of

menorrhagia. If other causes are ruled out, simple removal of
the myoma can be effective in reducing menstrual flow and
the surgical success rate is almost 100%. In addition, the uter-
ine submucosal fibroids account for 5% of female infertility
and inward-protruding intramural fibroids may cause miscar-
riage. Application of hysteroscopic removal of myomas may
eliminate laparotomy and avoid rupture of scarred uterus after
pregnancy. Therefore, hysteroscopic removal of uterine myo-
mas is more suitable for those who want to preserve fertility.
11.2.4 Ultrasonography Guidance for TCRS
The uterus is formed by fusion of the two paramesonephric

ducts. During the development process of the uterus, if two Fig. 11.10 On transverse scan of the uterus, two cavity echoes with a
longitudinal boundary in the center are visible
paramesonephric ducts are fused completely, but the septum
is not absorbed, complete septate uterus is formed. The ultra-
sonography shows that the uterus has a normal appearance
and the uterine cavity is isolated into two parts except that
uterine fundus has a wider transverse diameter. If the septum
is not completely absorbed, incomplete septate uterus is
formed. A typical malformation of septate uterus is that the
uterine cavity has two compartments in the corpus of the
uterus, and the transverse scanning of the ultrasonography
reveals that the uterus has a wider transverse diameter and
two cavity echoes, and there is a longitudinal boundary
(Fig. 11.10) in the center. On the longitudinal plane, the
septate tissues become thickened at the uterine fundus

(Fig. 11.11). After irrigation of distention medium, the ultra-
sonography scan in transverse plane shows the equally tiny
dense bright spots echoes formed by muscular tissues at the
center of uterine cavity, which are consistent with myome-
trial echoes. The uterus with bilateral fluid filling cavities Fig. 11.11 On longitudinal scan of the uterus, the thickened uterine
forms a “cat’s eye sign” (Fig. 11.12). fundus is partial septate tissues
Prior to transcervical resection of the septum (TCRS), on
the two-dimensional ultrasonography, the length of the sep-
tum, the widths of its base, and its distal end are measured.
Step one, the septum is resected. Under the double-
contrast ultrasonography guidance, the hysteroscopic wire
loop or needle electrode is used to resect or divide the sep-
tum from the distal end towards the basal portion.
Intraoperative cutting depth and direction are monitored by
ultrasonography. If the septum is long, its distal end may
generally be narrow, and the septum is usually resected with
wire loop between left and right interchangeably; if the sep-
tum is short and flat, its distal end is generally wider, and the
needle electrode can be used to divide and incise the septum
longitudinally. No matter which method is taken, when cut-
ting reaches the uterine fundus, the fundal portion appears to
be tapered or irregular (Fig. 11.13).
Step two, the uterine fundus takes shape. On ultrasonog- Fig. 11.12 On transverse scan of the uterus, the uterus with cavities on
raphy, the thickness in diameter of the anterior and the poste- both sides of septum filled with fluid forms a “cat’s eye sign”
358 D. Zhang
2–3 months. Therefore, hysteroscopic resection of septum is

easier to operate, with fewer complications and easily accepted
by patients, as compared to transabdominal surgery.
11.2.5 Ultrasonography Guidance for TCRA
Transcervical resection of adhesion (TCRA) is a procedure

applicable to any uterine adhesion and hematocele for a vari-
ety of reasons. The patients present with recurrent abdominal
pain, hypomenorrhea, amenorrhea, and infertility. Sometimes
menstrual blood may flow into the abdominal cavity and
cause severe abdominal pain similar to the ectopic preg-
nancy, and if not promptly treated, endometriosis may occur.
The traditional treatment of the intrauterine adhesions is to
Fig. 11.13 During operation, the fundus appears to be tapered swing a cervical dilator or a probe from one side to the other
in the uterine cavity to release adhesions. This method is
effective for mild, membranous, and some fibrous adhesions.
But for the severe, muscular, and some fibrous adhesions and
even uterine occlusion, the blind lysis of the adhesion may
easily cause damage to the uterine wall and even uterine per-
foration in severe cases. If hysteroscopic resectoscope is
used to divide the adhesions, ultrasonography guidance may
indicate the direction of the probe, and the direction and the
depth of electric cutting, which may not only ensure an
accurate incision of adhesions and guarantee the surgical
effects, but also can prevent effectively the occurrence of
uterine perforation.
As for mild intrauterine adhesions concomitant with
hematocele, under ultrasonography monitoring, a probe or a
cervical dilator is used to detect the uterine cavity, if they can
penetrate the adhesive zone and drain the hematocele, there
Fig. 11.14 After TCRS, the uterine fundus appears to be arc-shaped will be a clear visual field under hysteroscope. Then the
adhesive band adherent to the uterine wall is resected under
ultrasonography guidance. If a probe or a cervical dilator
rior walls of the fundus is measured, and then the excess cannot penetrate the adhesive zone, or there is severe adhe-
tissues are resected by the operator under guidance. After sion or complete uterine cavity occlusion, the probe or cervi-
each cutting, the cavity should be distended by irrigation cal dilator should not be inserted with force into the uterine
fluid and the morphology of the uterus should be observed by cavity to avoid uterine perforation. Under ultrasonography
ultrasonography. When ultrasonography shows that the guidance, the hysteroscopic resectoscope is introduced via
thickness of the fundus is consistent with that of the anterior the cervix into the lower portion of the adhesions, and the
and posterior walls, the uterine fundus appears to be arc- adhesions are resected along the uterine mid axis. After lysis
shaped and the cutting surface is flat, then the surgery is of adhesions, the irrigation fluid is injected into the uterine
completed (Fig. 11.14). cavity. When the ultrasonography reveals a good uterine dis-
Incomplete septate uterus is one of the causes of recurrent tension and intact lining, it suggests that the surgery is com-
pregnancy loss. Before the advent of hysteroscopic surgery, pleted (Figs. 11.15 and 11.16). In order to prevent reformation
the procedure of metroplasty is to remove the septum after of intrauterine adhesions, IUD is placed in the uterine cavity
transabdominal incision of uterus. Compared with hysteros- after surgery and removed 3 months later.
copy, transabdominal surgery has greater trauma, slows recov-
ery, and delays pregnancy for 1–2 years postoperatively.
Hysteroscopic surgery eliminates the pains caused by open 11.2.6 Ultrasonography Guidance for TCRF
surgery and avoids the rupture of scarred uterus after preg-
nancy and pelvic adhesions. Due to the quick recovery after Transcervical removal of foreign body (TCRF) is applicable
hysteroscopic surgery, the patients may have pregnancy after to embedded IUD, fragmented IUD residual, and placental
Fig. 11.15 Prior to surgery of peripheral intrauterine adhesions, adhe- Fig. 11.16 After resection of intrauterine adhesions, the uterine cavity
sions are seen at the lining of uterus with an irregular morphology of has a good distention
uterine cavity
or embryonic retention in the uterine cavity. Since the for-

eign body can elicit varied degrees of clinical symptoms and
different features of ultrasonography imaging, the corre-
sponding surgical approach should be adopted according to
different causes.
11.2.6.1 Removal of the Residual IUD

First to determine the location of the residual IUD under
ultrasonography. If part of the residual IUD is embedded in
the uterine wall, hysteroscopy can reveal its location and
ultrasonography can indicate the distance from the embed-
ded end to the serosal layer. If concomitant with uterine or
cervical adhesions, or if the intrauterine device is fully
embedded in the muscle wall (Fig. 11.17), the residual IUD Fig. 11.17 The residual IUD is embedded in the anterior wall of
uterus, which presents as strong echoes under ultrasonography scan
cannot be seen under hysteroscope. If so, the operator may
apply the ultrasonography monitoring to locate the residual
IUD by measuring the distance between it and the endome- 11.2.6.2 Removal of Complete or Broken
trial line and can resect or divide the adhesions, the endo- Metal Ring
metrium, and myometrial tissues in the surface of residual It is difficult to remove the embedded metal rings in the mus-
IUD, so that the fragmented end of it is exposed. Then the cle wall. First, under ultrasonography guidance, determine
hysteroscopic wire loop or oval forceps is used for its the location of the embedment. Then the hysteroscopic wire
removal. loop is used to incise the embedded tissues. Finally, the hook
360 D. Zhang
or oval forceps is used to take out the metal ring. During the cavity are resected hysteroscopically, followed by the resec-
clamping process, the metal wire of IUD may be twisted or tion of tissues adhered to or implanted in the muscle wall.
broken. Therefore, the entire process of removing the metal When ultrasonography indicates that the implanted or orga-
ring must be monitored continuously by ultrasonography. If nized tissues are in the deep myometrium or serosal layer,
there is a twisted or broken ring, ultrasonography shall indi- the resection should be performed according to the depth
cate whether the metal ring has been removed completely or indicated by ultrasonography to prevent cutting too deep and
not and locate the fragmented residual ring in the causing uterine perforation.
myometrium.
11.2.6.3 Removal of Fetal Bones 11.3 Ultrasonography Guidance

Fetal bone retention in the uterine cavity presents as strong and Uterine Perforation
echogenic mass with acoustic shadowing under ultrasonog-
raphy. If fetal bone is visible under hysteroscope, it can be Hysteroscopic operation is all implemented in the uterine
removed directly by hysteroscopy. If the fetal bone is large, cavity. Due to a narrow field of vision and hard to estimate
ultrasonography can indicate the relationship between the conduction of electricity, uterine perforation occurs some-
long axis of fetal bone and the long axis of uterine cavity, times, and its incidence can be as high as 2%. Therefore, the
which is helpful to its removal under hysteroscope. If fetal preoperative knowledge about high-risk diseases and intra-
bone retention is embedded in the myometrial wall or con- operative timely detection of uterine perforation are very
comitant with uterine adhesions, ultrasonography can reveal important.
if the strong echogenic mass lies in the uterine wall or if
there is irregular echo-free zone around the strong echogenic
mass, which is a sign of uterine adhesion concomitant with 11.3.1 Causes of Uterine Perforation
uterine hematocele or hydrohystera. Under ultrasonography
surveillance, the hysteroscopic wire loop can be used to 11.3.1.1 Intrauterine Myomas
resect the adhesions and remove the residual fetal bones or to As for a submucous myoma with broad pedicle or without
incise the muscle tissues in the embedded portion for the pedicle, its base is often deep into myometrium. As for
removal of the fetal bones. inward-protruding intramural myoma, of which 1/2 to 2/3
locating in the uterine wall, the myometrium at the outer
11.2.6.4 Removal of Residual Placental Tissues edge of myoma is squeezed to be very thin. Under ultraso-
Uterine wall adhesions, implantation, and (or) organized tis- nography monitoring, the simple removal of these two kinds
sues may develop due to the placenta residue. The ultraso- of fibroids by hysteroscopy rarely results in uterine perfora-
nography reveals inhomogeneous echogenic mass in the tion. After resection of myomas, the lining of uterus may
uterine cavity, which shows an unclear border with the uter- appear concaved, inward-protruding, or irregular. The exces-
ine wall (Fig. 11.18). Under ultrasonography guidance, the sive traction from the surrounding normal uterine muscle
placenta residue, and adhesive or organized tissues in uterine fibers of the large myomas may cause poor contraction of
uterus. After removal of myomas, if TCRE is performed in
the irregular and poorly contractile uterine wall, uterine per-
foration may occur easily.
11.3.1.2 Adenomyosis
Adenomyosis is developed by growth of the endometrium
from the basal layer to myometrium, within which the ecto-
pic endometrium is embedded. Endometrium in the myome-
trium is distributed diffusely or focally, causing reactive
hyperplasia of muscle fibers and fibrous tissues, which
makes the uterus enlarged evenly or unevenly. On ultraso-
nography, the uneven enlargement is often seen to be signifi-
cantly thicker in posterior wall than in anterior wall, and it
can also be significantly thicker in anterior wall than in pos-
terior wall. If the lesion is intensified locally, the contour of
uterus will be irregular, and its image on ultrasonography is
Fig. 11.18 The residual placenta tissues lie in the posterior wall of
uterus, showing strong echoes, and concomitant with intrauterine adhe- similar to that of uterine fibroids, but no clear capsule, which
sions and hydrohystera is the difference between adenomyosis and myomas. On rou-
tine ultrasonography scan, there are always no abnormalities developed poorly or missing, the placental villi may be
revealed in atypical adenomyosis. When the cutting depth of directly implanted into the myometrium, forming placenta
TCRE reaches myometrium, the strong echogenic band accreta. Either partial placental adhesions or partial placental
formed by the electrical thermal effect on muscular fibers implantation can affect the normal contraction and restora-
may last 15 min. When endometrium invades diffusely or tion of the uterus. Old placental adhesions and implantation
focally into myometrium, forming adenomyosis, even may cause irregular vaginal bleeding after delivery or mis-
though the cutting depth has arrived at myometrium, differ- carriage. The ultrasonography shows residual placenta as
ent durations of strong echogenic band produced by the elec- uneven echogenic mass protrudes into uterine cavity. At the
trical thermal effect on the muscular fibers and endometrial site of uterine wall where adhesion or implantation occurs,
tissues may disappear rapidly or intermittently due to the inflammatory cells are infiltrated, granulation tissue grows,
invasive endometrial tissues in the myometrium (Fig. 11.19). and the fibrous scar is finally formed. Under ultrasonogra-
This ultrasonography is different from the strong echogenic phy, it shows locally strengthened echoes. The adhered or
band formed after TCRE in patients without adenomyosis implanted uterine wall is hard while the surrounding normal
and is easy for monitoring physician to mistakenly believe wall is relatively soft. When hysteroscopic wire loop is used
that excision is not deep enough. At the same time, if the to resect the old adhesive tissues or implanted placental tis-
operator discovers the endometrial tissues reappear in the sues in the uneven hardness muscle wall, it is likely to cause
resected myometrial surface and there is old bleeding and a uterine perforation. If the placenta is implanted into deep
honeycomb structure, he will also believe that the resection muscle wall, when deep lesion is resected, there is higher
has not reached the desired depth. During the operation, probability of uterine perforation.
when adenomyosis is encountered, repeated cutting may
very easily cause uterine perforation. In addition, the uneven 11.3.1.4 Intrauterine Retention
distribution of lesions within the myometrium may cause the and Embedment of Fetal Bones
uterus to contract unevenly and change under the electrical Intrauterine retention of large fetal bone may lead to infertil-
thermal effect. The ultrasonography shows that the local ity, but generally may not cause changes in the structure of
thickening of the uterine wall may transfer from one uterine the uterine wall. If a fetal bone fragment is embedded in the
side wall to another along with the surgical process. If the uterine wall, a rejection reaction in local uterine wall will
operator sees the uterine wall locally swelling but ignores the develop, followed by the inflammatory cell infiltration,
uneven and changing features of uterine contraction and wrapping of fibrous tissues, and finally hyaline change of the
repeats cutting on the swelling site, uterine perforation may surrounding tissues, which leads to hard texture and poor
occur easily. elasticity of local tissues. Ultrasonography reveals spotty or
patchy high echoes within the muscle wall, and heteroge-
11.3.1.3 Placenta Residues neous moderate echoes in its surrounding tissues. If the fetal
When decidua is poorly developed, the residual placenta bone is embedded deep in the uterine wall, hysteroscopic
may adhere to the uterine wall and cannot shed by itself, thus resection with wire loop will be prone to cause perforation.
placenta adhesion is formed. If uterine decidual layer is If multiple fetal bone fragments are more intensively embed-
ded in one side of uterine wall, this may cause local uterine
wall to be soft and hard staggered structure. After hystero-
scopic wire loop is used to incise the endometrium and the
myometrium to expose the fetal bone, even the curette used
to scrape off the fetal bone in the muscle wall will be prone
to cause uterine perforation.
11.3.1.5 Severe Intrauterine Adhesions

Severe intrauterine adhesions may cause extensive adhesions
and stenosis of uterine cavity, even atresia. The synechia tissue
has a hard texture, while normal myometrial tissue is relatively
soft. When the probe or cervical dilator penetrates the obliter-
ated uterine cavity, if too much force is used or the direction of
introduction deviates from the uterine cavity, the probe or cer-
vical dilator may penetrate the softer myometrial tissues after
passing through the synechia tissues, leading to uterine perfo-
Fig. 11.19 The strong echogenic band formed in the lining of uterus ration or partial perforation. If it is a partial perforation, a false
appears to disappear intermittently passage may be created in the uterine wall. If both the ultraso-
362 D. Zhang
nography physician and the hysteroscopic operator do not uterine perforation is caused by cervical dilator, the trauma
detect the trauma to the uterine wall and continue to operate in area is large and ultrasonogram shows the interrupted echoes
the false passage, uterine perforation will result. in the uterine serosal layer. The uterine perforation caused by
electrical thermal damage is displayed on ultrasonogram as
11.3.1.6 Old Injuries in the Uterine Wall strong echoes formed by electrical thermal effect throughout
Different kinds of intrauterine procedures such as curettage, the uterine myometrium with interrupted echoes in the local
induced abortion, and diagnostic curettage may cause uterine serosal layer (Fig. 11.20). During operation, uterine perfora-
perforation or partial perforation in cases of improper operation caused by electrical thermal damage may lead to the
tion. If uterine perforation occurs, its clinical symptoms will irrigation fluid flowing into the pelvic and abdominal cavity
be significant; therefore, it can be managed in time after through the perforated site, which presents as irregular liquid
clinical or ultrasonographic diagnosis. If it is partial perfora- echo-lucent area on ultrasonographic imaging. If neither the
tion or smaller perforation, clinical symptoms may not be ultrasonography physician nor the operator detects the perfo-
typical and difficult to find clinically. When ultrasonography ration timely and stops the infusion of irrigation fluid, ultra-
in combination with hysteroscopy is performed in examining sonography can only reveal liquid echo-lucent area in pelvic
the old injuries induced by partial uterine perforation, the cavity. If the introduction of irrigation fluid is not stopped
ultrasonography reveals a wedge-shaped defect in the local timely, liquid echo-lucent area between liver and kidney and
uterine wall. The muscle wall where old injuries occur is dif- even between the intestine canals can be visualized.
ferent from the surrounding normal uterine wall in thickness,
hardness, elasticity, which constitutes one of the factors of
uterine perforation in hysteroscopic surgery. If it is an old 11.3.3 Intraoperative Monitoring and Uterine
uterine perforation and the injured muscle wall was not Perforation
repaired, any intrauterine procedures such as preoperative
exploration of the uterine cavity with a probe and dilatation In order to improve the safety of operation, the doctors who
of the cervix with cervical dilators, or intraoperative hystero- perform hysteroscopy will apply ultrasonography or laparos-
scopic resection of endometrium or lesions with wire loop, copy, or even laparoscopic ultrasonography to preventing
are prone to cause perforation. uterine perforation. Ultrasonography scan can guide the oper-
ation according to the thickness of uterine wall; laparoscopy
11.3.1.7 The Position of the Uterus may prevent the occurrence of uterine perforation according
The best position for hysteroscopic operation is horizontal to the change in uterine serosal surface; laparoscopic ultraso-
position (median). Most anterior or posterior uterus may turn to nography can combine both advantages, but the equipment
a horizontal position at surgery due to the traction on cervical has not yet been popularized, so its application is limited. It
forceps. As for a small number of uteri which are anteverted, should be emphasized that hysteroscopic operation relates to
anteflexed, or extremely retroverted, and concomitant with pel- many kinds of diseases, so intrauterine and uterine wall
vic adhesions, the position of uterus is more fixed and the trac- abnormalities are often unexpected. The degrees of surgical
tion on the cervical forceps cannot change its position. At
surgery, the detection of uterine depth with a probe, dilation of
cervix with cervical dilator, and the insertion of hysteroscope
may cause trauma to the uterine wall due to the introduction of
instruments into uterine cavity at an improper angle, and uter-
ine perforation may occur in serious cases. In particular, among
the patients who have undergone hysteroscopic surgery due to
intrauterine adhesions, the anteverted or retroverted uterus
increases the difficulty and dangers in the intrauterine opera-
tions. Therefore, the position of the uterus is also one of the
reasons affecting the safe intrauterine operation.
11.3.2 Sonographic Features of Uterine

Perforation
If uterine perforation is caused by improper operation of the

probe, the trauma area is small. If there is no irrigation fluid Fig. 11.20 Ultrasonography reveals interrupted echoes of uterine
infiltration, ultrasonogram shows no characteristic change. If serosa at the site of perforation
difficulties vary because of different etiologies, illness-histo- Transabdominal ultrasonography monitoring can be used
ries, and the operator’s clinical experiences. As for ultraso- in simple hysteroscopic surgeries like endometrial resection
nography surveillance, uterine perforation is hard to be and endometrial ablation to achieve the purpose of prevention
controlled in cases of difficult intrauterine procedures, sud- of uterine perforation. Experienced surgeons did not even
den changes in structure of uterine wall, high-frequency elec- need any monitoring methods. However for complex hystero-
tricity interference during hysteroscopic resection, and false scopic surgeries, such as removal of intrauterine foreign body
image created during intrauterine operation with metal embedded in the muscle wall, severe intrauterine adhesions,
devices, even for a very experienced doctor performing hys- and large inward-protruding uterine intramural fibroids, it is
teroscopic surgery under ultrasonography guidance. As for usually necessary to use ultrasonography or laparoscopic
laparoscopic surveillance, uterine perforation is also hard to monitoring of surgery. If the patient has a preoperative history
be prevented because it can only observe the changes on uter- of repeat intrauterine operations, damage to the uterine wall
ine serosa and may be influenced by its viewpoint. Therefore, and intrauterine adhesions will have developed; if the patient
regardless of the application of ultrasonography or laparos- has a history of abdominal surgery, pelvic adhesions will have
copy, the instant occurrence of uterine perforation cannot be been formed. Both conditions not only make the surgery
completely avoided and sometimes uterine perforation has more difficult, but also increase the difficulty in transabdomi-
occurred at the instant the operator sees the crisis of perfora- nal ultrasonography diagnosis and intraoperative ultrasonog-
tion. Once the uterine perforation occurs, what ultrasonogra- raphy guidance. The trauma to uterine wall includes the
phy reveals is indirect sign of uterine perforation, such as the uterine perforation and partial uterine perforation, and the
interrupted echoes in the serosal layer and liquid echo-lucent perforation site is more common in the uterine fundus. Old
areas emerging rapidly surrounding the uterus. Under the uterine perforation can be detected by laparoscopic examina-
guidance of ultrasonography, the effects of medicines like tion; partial uterine perforation is difficult to be identified by
oxytocin and hemostatic on the trauma of uterus may be laparoscopy, hysteroscopy, or transvaginal ultrasonography,
observed and the operator may be guided to draw fluid from but ultrasonography in combination with hysteroscopy can
the abdominal cavity. Ultrasonography scan is noninvasive, improve the diagnosis rate. In addition, the recent develop-
and its effect is indirect. Laparoscopy can directly confirm ment of laparoscopic ultrasonography makes a clearer obser-
uterine perforation and can repair the damaged uterine wall, vation of partial uterine perforation. Laparoscopic
so it is minimally invasive, and its role is direct. ultrasonography can distinguish the strong echo foci in the
myometrium from the residual fetal bones and differentiate
the strong echo formed after electric cutting of uterine wall
11.4 The Value of Ultrasonography from the residual IUD or fetal bone embedded in the muscle
Guidance in Hystersocopic Surgery wall. For complex hysteroscopic surgery, laparoscopic ultra-
sonography can improve the diagnosis and indicate the surgi-
The clinical applications of hysteroscopic surgeries includ- cal process so as to prevent uterine perforation effectively.
ing TCRE, EA, TCRM, TCRS, TCRA, and TCRF provide In short, transabdominal ultrasonography is the preferred
chances of cure for patients with dysfunctional uterine method in the guidance of hysteroscopic surgery due to its
bleeding or intrauterine benign lesions, especially those simplicity and non-invasiveness. There is no doubt that the
who cannot tolerate open surgery. However, since the sur- intervention of laparoscopy can detect timely any damage to
gery is performed in the uterine cavity, the surgical field of the uterine wall and even suture the perforated uterus, which
vision is narrow and the electric energy used in operation can avoid serious consequences and compensate for the
has a certain penetration, the possibility of uterine perfora- absence of transabdominal ultrasonography guidance. The
tion is the main reason for this procedure taking time to advent of laparoscopic ultrasonography offers chances of the
become popularized. In the early stages of carrying out this successful complex hysteroscopic surgery. Being an invasive
operation, the scholars have advocated laparoscopic moni- examination, laparoscopy and laparoscopic ultrasonography
toring of the operation. However, because laparoscopy can- are not appropriate for regular methods of guidance of hys-
not indicate the occurrence of posterior uterine wall teroscopic surgery.
perforation, uterine perforation still occurs sometimes. In
1987, Lin BL from Japan first used ultrasonography in the
guidance of hysteroscopy, which was mainly used in TCRM Suggested Reading
and TCRS. In 1990, Xia EL from the Hysteroscopy Center
of Fuxing Hospital, Capital Medical University, began to 1. Chen C, Lu Z. Color Doppler diagnostics in obstetrics and gyne-
cology. Beijing: People’s Health Publishing House; 1998. p. 25–9.
use ultrasonography in monitoring TCRE, and then its use is Chinese.
extended to TCRM, TCRS, TCRA, TCRF, and EA, which 2. Coccia ME, Becattini C, Bracco GL, Bargelli G, Scarselli
created the conditions for the development and populariza- G. Intraoperative ultrasound guidance for operative hysteroscopy.
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364 D. Zhang
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septum: a report of 27 cases. China J Endosc. 1998;4:48–9. Chinese. roscopic monitoring in hysteroscopic operation. China J Endosc.
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Reprod Med. 1999;44(7):642–4. gia: analysis of 400 cases. Chin J Obstet Gynecol. 1997;32:148–51.
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agement and reproductive outcome. Fertil Steril. 2000;73(1):1–14. sound in transcervial resection of myomas. Chin J Med Imaging.
7. Kresowik JD, Syrop CH, Van Voorhis BJ, Ryan GL. Ultrasound 2001;9:268–9. Chinese.
is the optimal choice for guidance in difficult hysteroscopy. 17. Zhang D, Liu J, Meng Y. Ultrasound guidance for hysteroscopic
Ultrasound Obstet Gynecol. 2012;39(6):715–8. resection of intrauterine foreign body. Chin J Med Imaging.
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9. Kuzel D, Tóth D, Fucíková Z, Cibula D, Hrusková H, Zivný sound and hysteroscopy to postmenopausal uterine bleeding. Chin
J. Hysteroskopická resekce submukózních myomů pri abnor- J Med Imaging. 2000;8:30–1. Chinese.
málním dĕlozním krvácení: výsledky ctyrleté prospektivní studie 19. Zhang D, Meng Y, Liu J. Application of laparoscopic ultrasonog-
[Hysteroscopic resection of submucosal myomas in abnormal uter- raphy in gynecologic surgery. Chin J Ultrasonogr. 1999;8:344–6.
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Complications of Hysteroscopic Surgery
12
Enlan Xia, Rafael F. Valle, Xiaowu Huang, Dan Yu,
Yuhuan Liu, and Baoliang Lin
Complications are defined as clinical incidents that occur form hysteroscopic operation safely, the surgeon must be
and cause the surgery to be suspended of further treatment fully aware of various complications and the ways for early
during operation and which requires a long time of monitor- detection and preventive treatment.
ing and further laparoscopic investigation or surgery. In
2000, Propst et al. reported that in 925 cases of hysteroscopic
surgery, the occurrence rate of operative complications was 12.1 Organ Injury
2.7%. These complications involved uterine perforation,
fluid overload (≥1 L), hyponatremia, hemorrhage (≥500 mL), Enlan Xia
bowel or bladder injury, difficulty in dilating the cervix, pro-
longed hospitalizations, etc. TCRM and TCRS had the great-
est probability of complications with fluid overload the most
frequent complication. TCRP and TCRE had the lowest 12.1.1 Uterine Perforation
probability of complications. Hysteroscopic operative com-
plications, although rare, are serious. There are four kinds of Perforation of uterus is the most common complication of
major complications: (1) Hyponatremic encephalopathy, or hysteroscopic surgery related to operators. If not found in
TURP syndrome, is one of the most serious complications. It time, large amount of irrigation fluid may flow into the
has been reported that premenopausal women are 26 times abdominal cavity, and conventional instruments, or instru-
more likely to suffer neurologic sequelae from hyponatremia ments with laser or electric energy may pass through the per-
than postmenopausal women or men. These women will forated uterus into pelvis and damage adjacent organs. Then
experience permanent brain damage, paralysis, and even uterine perforation will be concomitant with fluid overload,
death. To prevent this complication, premenopausal women injuries to digestive tract and urinary tract, and rupture of
could be transited to postmenopausal state prior to operation major vessels, causing fatal complications such as peritoni-
by using GnRH agonists in sufficient dosage and for a suffi- tis, fistula, heavy bleeding, and air embolism. Therefore, it is
cient length of time to induce menopause. Carter reported on also the most serious complication (Fig. 12.1a, b).
one healthy young woman who suffered irreversible neuro-
logical consequences from hyponatremia during a hystero- 12.1.1.1 Incidence
scopic resection of a small submucous myoma. (2) Uterine Perforation of the uterus is the most common complication
perforation (either with or without bowel injury). (3) of hysteroscopic surgery. In 2005, MacNeil reported that its
Hemorrhage. (4) Infection. In addition, there may be air occurrence rate was 1–10%. In literature reviewed over
embolism which may cause sudden death. Therefore, to per- nearly 15 years, the incidence rate was 0.25–25%
(Table 12.1), and the average rate was 1.22% (785/64,198).
E. Xia (*) · X. Huang · D. Yu · Y. Liu
Hysteroscopy Center, Fuxing Hospital, Capital Medical University, 12.1.1.2 Factors for Occurrence of Uterine
Beijing, China Perforation
R. F. Valle 1. The operator’s experience: The occurrence of uterine per-
Department of Obstetrics and Gynecology, Northwestern foration is obviously related to operator’s experience.
University Medical School, Chicago, IL, USA
Most perforations occur in the first stage of operation. For
B. Lin an inexperienced operator, the occurrence of complica-
Department of Obstetrics and Gynecology, Kawasaki Municipal
tion is always hard to avoid and difficult to manage.
Hospital, Kawasaki, Japan

366 E. Xia et al.
a b
Fig. 12.1 Uterine perforation. (a) Caused by laser optical fiber. (b) Caused by scissors
Along with the progress in training, experience, and absolutely safe. In the early stage of EA, there were
skills, less and less perforations of the uterus occur. reports about intestine-uterine fistula.
Therefore, the operator’s training is very important. The 4. Types of surgeries: TCRA and TCRS are more likely to
future goal is to teach the staff at the operating room how cause perforation than TCRM, TCRE, and TCRP. In the
to identify and treat complications so as to ensure that Hysteroscopy Center of Fuxing Hospital, Capital Medical
patients may achieve better prognosis. University, 2006 hysteroscopic procedures were per-
2. Anatomical location of perforation: Perforation occurs formed, of which uterine perforation occurred in eight
mostly at the site of uterine wall where it is prone to per- cases (0.4%), including three cases of intrauterine adhe-
forate, such as the cornua of uterus and uterine isthmus, sions. Horak reported that the incidence of uterine perfo-
and they are the sites most difficult to resect. ration was 2.13%. Bukulmez et al. performed
3. Active electrodes: The most commonly used electric hysteroscopic lysis of total corporal synechiae caused by
energy and laser all may elicit accidental injury. Since the endometrial tuberculosis, and the incidence of uterine
long rod device with electricity or laser is used in the nar- perforation was 25%. Roge et al. reported that the uterine
row uterine cavity, the cooperation of eyes, brain, hands, perforation rate during TCRS was 5.88%. Data from
and feet is very important. Accurate positioning is Choe et al. showed that the uterine perforation rate after
required, and only when the electrode is accurately in TCRS was 5.26%. It can be concluded that septate uterus
place, the electrode or laser can be powered up. In the and intrauterine adhesions are high-risk factors for intra-
currently used electrocoagulation and electroresection, operative uterine perforation and should be closely moni-
the amount of thermal damage produced by its high- tored and precautions should be taken.
frequency current is beyond computation, and the dis- 5. Past history of uterine trauma: Itzkowic and Beale reported
tance of thermal conduction is unpredictable. The calorific that in three cases of uterine perforation, two cases had
value of denatured enzyme is 57 °C. Undetectable ther- history of cesarean section, and one had curettage. Daniell
mal necrosis will occur to the tissues at this temperature, et al. reported that 1 woman who experienced perforation
and if it occurs to the bowel or bladder, the consequences during hysteroscopic surgery had a history of
are unimaginable. A case who suffered from generalized HEAL. Alford et al. reported that one case of perforation
peritonitis after TCRE was reported. By laparotomy, the occurred during the second EA. Jansen et al. reported
uterine wall was seen to be locally pale and degenerated, about the data on complications of diagnostic and opera-
and there were two perforations in the small intestine. tive hysteroscopy recorded by 82 hospitals in 1997, which
Application of mechanical energy is safer than using were categorized into two groups: (1) approach related
laser or electric energy, and cutting with wire loop elec- complications being caused by introduction of the instru-
trode during TCRE is more likely to cause perforation ments; (2) instrument related complications being caused
than with rollerball electrode for electrocoagulation. The by surgical technique with hysteroscopic instruments.
operator with less experience may use rollerball electrode Among 13,600 hysteroscopic procedures analyzed, com-
to coagulate on the site of easy perforation, but it is not plications occurred in 38 cases (0.28%).
12
Table 12.1 Uterine perforation during hysteroscopic surgery
Uterine perforation
Author Year No. of cases Method No. of cases % Notes
Peterson et al. 1990 7293 Electroresection 95 1.3 Collected by AAGL
Magos et al. 1991 250 TCRE 4 1.6 –
Pecrutto et al. 1991 54 HEAL 2 3.7 One case of bowel injury
Horak et al. 1992 141 TCRA 3 2.13 All under laparoscopic monitoring
Itzkowic and Beale 1992 – EA 3 – Two cases with previous cesarean section and one case with previous D&C
Daniell et al. 1992 64 EA 1 1.56 Previous history of HEAL
Hucke et al. 1992 39 TCRM 1 2.6 Small bowel injury
Choe et al. 1992 19 TCRS 1 5.26 –
Sullivan et al. 1992 – TCRM 1 – Suspected during operation and identified laparoscopically. By laparotomy,
sigmoid perforation was discovered and was repaired
Hulka et al. 1993 17,298 Electroresection 190 1.1 Collected by AAGL, eight cases of bowel injury
Chen et al. 1994 28 Electroresection 1 3.57 –
Huvar et al. 1994 34 Electroresection 1 2.9 Perforation during TCRM
Hulka et al. 1995 14,707 Electroresection 208 1.42 Collected by AAGL
Osei et al. 1995 90 HEAL 1 1.1 Perforation suspected but was not confirmed at subsequent hysterectomy
Tapper et al. 1995 86 TCRE 1 1.16 –
Hallez et al. 1995 284 TCRM 1 0.35 –
Scottish Hysteroscopy 1995 987 Electroresection 10 1 Concomitant with obvious fluid overload
Audit Group et al.
Valos et al. 1996 800 EA 7 0.88 Data from 54 hospitals
Cravello et al. 1996 395 Electroresection 1 0.25 Complicated by intraabdominal bleeding
Cravello et al. 1996 102 TCRE 1 0.98 All were menopausal women
Alford et al. 1996 – EA 1 – A second EA
Brian et al. 1996 126 TCRE 2 1.59 No serious consequences
Roge et al. 1996 102 TCRS 6 5.88 –
Leuschner et al. 1997 3144 Electroresection 62 2 Data from 99 hospitals
Mints 1998 70 TCRE 1 1.42 –
Castaing et al. 1999 352 Electroresection 14 4 Three cases complicated by bowel perforation
Toth et al. 1999 1410 Electroresection 1 0.7 –
Bukulmez et al. 1999 12 TCRA 3 25 Laparoscopic suturing
Jansen et al. 2000 2500 Electroresection 19 0.76 –
Schiotz 2001 348 TCRE 3 0.9 One case of investigative laparotomy
Ravi et al. 2001 70 TCRE 6 8.6 One case complicated by bladder and ureteral injury
Cravello L et al. 2002 2116 Electroresection 34 1.61 33 cases received intraoperative treatment with no sequelae
Xia Enlan 2003 3541 Electroresection 16 0.45 Data from five hospitals
Agostini 2003 2116 Electroresection 34 1.61 74 (3.5%)had complications
Parkar RB 2004 463 Electroresection 2 0.43 Both occurred during TCRM
Duan Hua 2005 4171 Electroresection 11 0.26 Seven cases of partial perforation
Boe et al. 2006 386 Electroresection 31 8 Two cases underwent laparoscopy
Shveiky D et al. 2007 600 Electroresection 6 1 The incidence of complication is 3% for an experienced operator
367
368 E. Xia et al.
12.1.1.3 Identification of Uterine Perforation rence of perforation in one case during HEAL using laser
Generally, intraoperative uterine perforations may be fiber, which was not confirmed at subsequent hysterectomy.
detected in the following steps. It indicates that assessment of uterine perforation by hyster-
oscopy is not always accurate.
1. Once uterine perforation occurs, the irrigation fluid may
extravasate into the abdominal cavity. Ultrasonography 12.1.1.4 Seriousness of Uterine Perforation
may reveal that there is free liquid around the uterus pre- The seriousness of uterine perforation depends on the instru-
ceding the clinical symptoms, or under ultrasonography ment causing perforation and the time of detection. As long
monitoring a large amount of irrigation fluid is seen sud- as it is timely detected and treated, there will be no serious
denly rolling into the abdominal cavity. consequences.
2. The site of perforation communicates with abdominal
cavity. The peritoneum, the bowel, or omentum are visi- 1. The uterine perforation may be caused by surgical instru-
ble under hysteroscope, which can be easily identified by ment, such as cervical dilator, resectoscope, oval forceps,
an experienced laparoscopic operator. However, it is dif- curette, etc. Valos et al. reported uterine perforation
ficult for an operator without laparoscopic experience to occurred in one case from laminaria, four cases from dila-
make a diagnosis accordingly. tor, and two cases from resectoscope. Magos et al.
3. Under laparoscope, the serosa is seen to be translucent reported on one case of uterine perforation during the
and blistery, and there is bleeding, hematoma, or insertion of resectoscope. Serden and Brooks reported
perforation. one perforation at the time of taking out myoma frag-
4. The patient is seen suddenly deteriorating, the blood pres- ments. These perforations did not cause damage to the
sure drops and heart rate quickens. Ultrasonography scan abdominal viscera and vessels. If perforation occurs in
reveals a large amount of free fluid in the abdominal the beginning, the operation will be compelled to stop; if
cavity. it occurs during operation, the laparoscopy may do with
5. The bowel is clamped out from uterine cavity: The oval it; and if there is bleeding at the site of perforation, sutur-
forceps are introduced through the site of perforation into ing or coagulating bleeding points can be done under
the abdominal cavity and clamp the bowel out, or the laparoscope, and there is no need of laparotomy for
bowel is herniated into the uterine cavity through the site investigation.
of uterine perforation and clamped out with the oval 2. If perforation is from wire loop electrodes or laser optical
forceps. fiber, it can injure the organs adjacent to uterus, such as
6. Under laparoscopic monitoring, the fluid is seen to the bowel, bladder, large blood vessels, ureter, etc., and
increase sharply in the abdominal cavity. laparotomy is needed immediately for investigation. If
7. The operator should be alert against the progressive peri- perforation occurs when rollerball electrode is used for
toneal expansion. electrocoagulation, electrical thermal damage can affect
other adjacent organs, such as bladder and bowel. Several
In the Hysteroscopy Center of Fuxing Hospital, Capital days later, the postoperative symptoms like diarrhea,
Medical University, 11 cases of uterine perforation were col- fever, hematuria, and pain may appear.
lected. Among 11 cases of uterine perforation, three perfora-
tions occurred during diagnostic hysteroscopy with the 12.1.1.5 Treatment of Uterine Perforation
incidence rate being 0.03% and intrauterine adhesions being First, look carefully for the site of perforation and decide on
the indication; eight perforations occurred during operative the treatment scheme. If there is uterine fundal perforation,
hysteroscopy with the incidence rate being 0.4%. Their the peritoneum, omentum, or small intestines will be visible.
pathogeneses and treatments are seen in Tables 12.2 and Since the myometrium in the uterine fundus are thick and
12.3. there are relatively fewer blood vessels, there will be less
Despite the above tips, some uterine perforations fail to bleeding, and oxytocin and antibiotics can be used under
be timely detected but is found only when acute abdominal observation. The irrigation fluid into abdominal cavity may
pain occurs 1–2 days later. Osei et al. suspected the occur- be extracted by puncture of posterior fornix and generally
Table 12.2 Occurrence and treatment of uterine perforation in three cases of diagnostic hysteroscopy
No. Indications Perforation instrument Clinical manifestations Treatment
1 IUA Probe No Cured by oxytocin and antibiotics
2 IUA Probe Lower abdominal pain Cured by oxytocin and antibiotics
3 IUA Curette Severe lower abdominal pain and generalized Cured by laparotomy and hysterectomy
peritonitis 48 h later
12
Table 12.3 Occurrence and treatment of uterine perforation in eight cases of operative hysteroscopy
No. Process of the operation Perforation instrument Clinical manifestations Treatment

1 TCRE with deep cutting on left cornu Wire loop electrode Shock. Ultrasonography reveals a large amount of Cured by oxytocin and antibiotics
fluid in abdominal cavity
2 TCRE with deep cutting on the fundus Wire loop electrode Peritoneum is visible under hysteroscope Cured by oxytocin and antibiotics
3 TCRM for a submucous myoma of 7.2 cm. Too Wire loop electrode Severe lower abdominal pain Cured by laparotomy, subtotal
deep cutting caused sigmoid perforation of 1.8 cm hysterectomy, and repairment of bowel
4 TCRM for an inward-protruding intramural myoma Wire loop electrode Uterine injury and bleeding are discovered under Cured by laparotomy and hysterectomy
of 5.4 cm, and with a narrow cavity laparoscope
5 TCRA for intrauterine adhesions with a narrow Needle electrode Ultrasonography reveals irrigation fluid into the Cured by oxytocin and antibiotics
cavity abdominal cavity
6 TCRA and TCRF for intrauterine adhesions and Wire loop electrode Enhanced light transmittance of uterine wall and Cured by oxytocin and antibiotics
fetal bone retention partial uterine perforation are visible under
laparoscope
7 TCRE for DUB and adenomyosis. Too deep cutting Wire loop electrode Hysteroscopy reveals omentum majus tissues and Cured by laparotomy, total hysterectomy,
caused 1 cm injury at the bottom of bladder ultrasonography reveals irrigation fluid into the and repairment of bladder
revealed by laparotomy abdominal cavity
8 TCRA and TCRF for intrauterine adhesions and Wire loop electrode Uterine fundal perforation is visible under Cured by bipolar electrocoagulation for
fetal bone retention laparoscope hemostasis
369
370 E. Xia et al.
there are no serious consequences. The perforations in uter- the wire loop electrode used for resection of myoma slides
ine side wall and in the isthmus of the uterus are risky, which here, it is also easy to cause perforation. The uterine fundus
might cause damage to the uterine vasculature, so laparot- in some septate uteri are saddle-shaped, hence TCRS is
omy is needed immediately for exploration. If perforation is likely to cause perforation in the fundus, and laparoscopic
not clear, laparoscopy shall be performed even though the monitoring can be somewhat helpful. TCRA is most likely
general physical condition is normal, in order to observe to cause perforation of the uterus, which is generally due to
whether there is bleeding and its sources. Bleeding at the site the narrow and small uterine cavity, and its occurrence may
of perforation can be arrested by laparoscopic bipolar elec- be reduced if carefully operated using a resectoscope with
trocoagulation, and for larger perforation, suturing is needed. small outer sheath diameter (7 mm), under monitoring of
Choe and Baggish reported that a small perforation of the ultrasonography, and by experienced doctors.
uterus was caused by hysteroscopic resection of uterine sep-
tum with the Nd-YAG laser, and no treatment was required. 12.1.1.7 Long-Term Prognosis of Uterine
If the patient has 24-h pain after operation, a comprehen- Perforation
sive examination shall be conducted, and if uterine perfora- With the widespread application of operative hysteroscopy,
tion is suspected, laparoscopic exploration shall be promptly the long-term complications have appeared gradually. In
performed. combination with the literature reported, ten cases of preg-
nancy after hysteroscopic surgery had uterine rupture
12.1.1.6 Prevention of Uterine Perforation (Table 12.4) in recent years, which included five cases after
1. Ultrasonography and (or) laparoscopic monitoring: TCRS, two cases after TCRA, and one case after
During ultrasonography monitoring, the heat from laser TCRM. Among them, 6 women had a history of uterine per-
vaporization and electric cutting may cause the basal foration during hysteroscopic surgery and uterine rupture
muscle tissue to dehydrate, forming a strong echo. When occurred at the site of previous perforation scar in late preg-
the strong echo reaches the serosal layer, it indicates that nancy. It is worth noting that two cases having no previous
continued cutting at this site will induce uterine perfora- uterine perforation also had uterine rupture in late pregnancy.
tion. Laparoscopy is used for observation of changes in Both cases had relatively weak uterus, including one having
the uterine serosal surface, such as the enhanced light a history of uterine perforation caused by IUD placement
transmittance in local uterus and the blisters in the serosa, and another having a history of repeated curettage. It indi-
which is indicative of impending perforation of uterus. cates that the uterus after operative hysteroscopy has obstet-
There were eight cases of uterine perforation analyzed in ric risk of uterine rupture.
the Hysteroscopy Center of Fuxing Hospital, Capital
Medical University, all of whom had been monitored by
ultrasonography and (or) laparoscopy during operation, 12.1.2 Injury to Adjacent Organs Induced by
but perforation could not be completely prevented. Loffer Uterine Perforation
believed that the role of laparoscopic and ultrasonogra-
phy monitoring during operation was limited. Shalev The most common injury to adjacent organs induced by uter-
et al. reported 128 women who underwent hysteroscopic ine perforation is intestine injury, accounting for 2.25% of
surgery under ultrasonography guidance. No occurrence uterine perforation (14/622). More perforations occur in the
of intra- or postoperative complications including perfo- colon and rectum and extremely rare in the small intestine.
ration was discovered. So it was believed that hystero- When perforation is discovered during operation, laparo-
scopic surgery for intrauterine pathologies under scopic suturing can be performed. When perforation of the
ultrasonography guidance could avoid the application of colon occurs, due to the extremely complex bacterial groups
unnecessary laparoscopy. in colonic contents, in order to avoid the contamination of
2. Operational problems: When there is unclear field of the abdominal cavity, the abdominal cavity should be thor-
vision, hysteroscopic electrode must not be powered up. oughly rinsed after intestinal suturing, and the drainage tube
When cutting during TCRE, the depth of cutting must be is placed in the abdominal cavity or the intestine is placed by
well controlled. When activated during EA, the rollerball exteriorization. Those perforations not discovered during
or vaporizing electrode must keep rolling. During TCRM, operation may develop peritonitis within days after operation.
if the myoma is large, it may fully fill uterine cavity, which Therefore, those who have uterine perforation should require
leads to a narrow visual space. When it is difficult to pull close observation in the hospital for a few days. Bladder
back the wire loop, the electrified wire loop is easy to injury occurs occasionally with urinary leakage. Due to the
injure the muscle wall opposite to myoma, causing perfo- urine being bacteria-free, if suturing is done in time, the
ration. The expansive growth of myoma stretches and thins patient may have a good prognosis. Laparoscopy can detect
the muscle wall adjacent to the edge of the myoma, and if and determine the injuries to pelvic organs, but is not abso-
12 Complications of Hysteroscopic Surgery 371
Table 12.4 Uterine rupture in pregnant patients after hysteroscopic surgery

Past history of surgery
Author Year No. of cases Types Perforation Pregnancy outcomes
Creinin et al. 1992 1 TCRS Yes Term birth of twins by cesarean section, with a 7 cm defect in the uterine
fundus identified
Halvorson et al. 1993 1 TCRS No Uterine rupture during pregnancy after surgery
Howe 1993 1 TCRS Yes Uterine rupture at 33 weeks of gestation, leading to neonatal death
Yaron et al. 1994 1 TCRM Yes Acute abdominal pain at 33 weeks of gestation and uterine rupture was
detected
Lobaugh et al. 1994 1 TCRM No Preterm cesarean section, with a 3.5 cm × 3.5 cm perforation revealed in
the uterine fundus
Gurgan et al. 1996 1 TCRA Yes Severe abdominal pain at 36 weeks of gestation, followed by cesarean
section. A 2 cm break at the original site of perforation in the uterine
fundus was detected
Tamnous et al. 1996 2 TCRS Yes Uterine rupture during pregnancy
TCRA No Uterine rupture during pregnancy
Gabrele et al. 1999 1 TCRS Yes Uterine rupture during induction of labor with PGE2
Chokri et al. 2000 1 TCRS No Uterine rupture during pregnancy
lutely reliable. Sullivan et al. reported that a 31-year-old

woman was suspected of uterine perforation during TCRM
for a pedunculated myoma. An uterine perforation was
revealed under laparoscopy, but sigmoid perforation was
identified by laparotomy, both of which were repaired in
consequence. So they believed that laparoscopy was not suf-
ficient in evaluating all injuries caused by perforation.
12.1.3 Large Vessel Injury Following Uterine

Perforation
There has been a case report that the injury to the aorta, the
external iliac, and internal iliac vessels can cause hemoperi- Fig. 12.2 Formation of false passage induced by hysteroscopy (The
toneum, leading to sudden death, and also case report about hysteroscope penetrates into the muscle wall and the false passage is
the injury to the mesentery and sacral vessels. If the injury to produced. The normal uterine cavity is at lower left of the false
uterine blood vessels happens, there will be rapid bleeding passage)
and formation of hematoma, which can move the uterus to
the opposite side. developed rapidly in the past 20 years. Even if the bleeding
disorders cannot be fully treated by blind intrauterine opera-
tion and require hysterectomy, it now may be treated effec-
12.1.4 Other Injuries tively in a minimally invasive environment. In the early
1980s, new techniques such as resectoscope utilized the
Valos et al. reported the formation of false passage during high-frequency electric energy source in hysteroscopic oper-
cervical dilatation in six cases (Fig. 12.2). There was also a ation, which provides an economical, practical, and simple
case report on tearing of posterior fornix due to the unsmooth way in the clinical treatment of intrauterine diseases. For
cervical dilation. intrauterine operation, different hysteroscopic instruments
require different low-viscosity liquid media in irrigating
uterine cavity, and the media can be electrolyte or electro-
12.2 Fluid Overload lyte-free fluid. However, the fluid distention media may pro-
vide a good field of vision in irrigating the uterine cavity, and
Rafael F. Valle, Enlan Xia, and Xiaowu Huang meanwhile, it brings potential dangers to patients. In some of
the more complex operations like endometrial resection and
With the development of endoscopic equipment and improve- resection of broad-based or inward-protruding myoma, the
ment of operative instruments, operative hysteroscopy has long-time exposure of open vessels in endometrium and
372 E. Xia et al.
myometrium to the distention media during operation can as a permeable material, there is possibly an increase in
cause large amounts of low-viscosity fluid absorption, result- plasma volume when in use.
ing in fluid overload. The use of fluid without sodium ion In the late 1970s and early 1980s, the high-viscosity liq-
may also cause pulmonary edema and hyponatremia. This uids were commonly used as distention media in hystero-
issue has caught the attention of endoscopic doctors and pre- scopic surgeries, such as 32% dextran or Hyskon solution.
ventive measures against this complication have been taken, Compared with low-viscosity liquids, this kind of fluid is
and positive and correct treatment has been administered to viscous and has a poor flowability in the uterine cavity and
the symptomatic patients. cannot produce a clear vision during surgery in the absence
of equipment with continuous irrigation, so currently it has
been less used clinically. However, due to its high viscosity
12.2.1 Physiology of Low-Viscosity and less amount of return flow used in uterine irrigation, only
and Electrolyte Fluid a small amount of uterine distention media is needed to com-
plete the operation, so it can also be chosen as special disten-
Clinically, when non-gastrointestinal tract is used for fluid tion media. However, we must pay attention to the stronger
replacement (such as intravenous infusion), the plasma permeability of high-viscosity liquids. When the intrauterine
osmotic pressure must be maintained between 280 and operation is implemented for a longer time, the decrease in
300 mOsm/L. Most intravenous fluids contain substances the amount of outflow of the uterine irrigation fluid means an
maintaining plasma osmotic pressure. Electrolytes are the increase in the amount of absorption by the body. When this
main substances to maintain the osmotic pressure in electro- high-viscosity liquid enters the blood circulation, the plasma
lyte fluids, but in electrolyte-free fluids, such as glycine, sor- osmotic pressure may be increased and pulmonary edema
bitol, and mannitol, these substances will soon be metabolized may be induced. When in vivo absorption volume is more
in the vessels, causing a decrease in overall level of plasma than 500 mL, it may also cause dysfunction of coagulation
osmotic pressure, thus leading to fluid overload. factors, thus leading to heavy bleeding and abnormalities of
In electrolyte solutions such as Ringer’s lactate, saline, fibrinogen, coagulation factor V, coagulation factor VIII,
and 5% glucose with normal saline, sodium, chloride, and coagulation factor IX, and VIII-Von Willebrand factor. At
bicarbonate ions can maintain the overall level of plasma this time, about ten times of the amount of dextran absorbed
osmotic pressure. Even if there is excessive fluid absorption retains in the capillary through osmotic absorption. What
in some extent, patients may not present with pulmonary needs to point out is that the relative molecular weight of
edema and hyponatremia. However, electrolyte-free solu- dextran is greater (>70,000) and cannot be filtrated by the
tions, such as 1.5% glycine, 3% sorbitol, and 5% mannitol, kidneys. Moreover, it has a half-life of 6–7 days in blood
due to lack of electrolyte composition, cannot sustain the circulation. Once fluid overload occurs and application of
overall level of plasma osmotic pressure. Therefore, the early diuretics is invalid in its correction, only blood dialysis ther-
accumulation of fluid in the microcirculation can induce pul- apy can be taken.
monary edema and hyponatremia.
1.5% glycine, a non-electrolyte distention medium, being
a sterile, nonpyrogenic, and low-permeability solution, is 12.2.2 Fluid Overload and Dilutional
widely used in transurethral resection of the prostate. The Hyponatremia
osmolarity of this fluid is 200 mOsm/L. Ammonia and oxa-
late in its degradation products may cause mental disorder, Not all hysteroscopic surgery must be performed with high-
and oxalate can also form deposits in the kidney in the form frequency electricity. The mechanical operation under hys-
of crystalline. teroscope or the surgical operation with laser as energy
Three percent sorbitol is also a kind of non-electrolyte source is also widely used clinically. In this kind of surgery,
distention medium, electrically nonconductive, and with there is no intervention of electricity, so we need not exclude
osmolarity 165 mOsm/L. Being reduction of glucose, sorbi- the presence of conductor in the distention media. Therefore,
tol may form carbon dioxide and water in the body and is it is better to choose the electrolyte media in irrigation of
excreted by kidneys. uterine cavity, such as Ringer’s lactate, normal saline, and
Five percent mannitol is inert fluid with an osmolarity of 5% glucose saline. Although the presence of electrolyte in
270 mOsm/L. It has a diuretic effect, which helps to rid the this type of fluid is relatively less risky in causing water
body of excess fluid absorption. Six to 10% of mannitol intoxication, excess absorption may still lead to fluid over-
absorbed into the body is involved in metabolism, and the load. Thus a close intraoperative monitoring must be con-
part without being metabolized is excreted by the kidneys. ducted in the amount of inflow and outflow of irrigation
Although mannitol has half-life of only 15 min in the plasma, fluid. When the in vivo absorption volume is more than
1.5–2 L, diuretics should be used immediately to prevent reasoned out. However, the accurate amount of fluid absorp-
pulmonary edema (Tables 12.5 and 12.6). tion cannot be calculated using this method, especially the
When the distention fluid is used in irrigating the uterine fluid into the tissue space, which can only act as a method for
cavity, attention must be paid to the following factors: (1) auxiliary monitoring.
intrauterine pressure should be controlled below 100 mmHg Clinically, fluid overload usually occurs in the use of
and not exceed the level of mean arterial pressure (MAP); (2) electrolyte-free liquid for irrigation and distention of uterine
the operating time should be controlled in no more than 1 h; cavity. Therefore, during operation using this type of disten-
(3) the excessive resection of uterine myometrial tissues tion media, it is very important to detect continuously the
should be avoided. concentration of electrolyte in blood, especially the concen-
Although hysteroscopic fluid pump can control the intra- tration of blood sodium. Currently, the microcomputer-
uterine pressure, still special attention should be paid to the controlled testing equipment can be used to monitor various
changes in the intrauterine pressure in the surgical treatment blood biochemical indexes while the operation is being per-
of lesions in the muscle wall. If the depth of myometrial formed. Using this method, only a small amount of blood
resection is 3–4 mm, the amount of irrigating fluid into the can help to understand the levels of electrolyte, especially
blood vessels will increase along with an increase in intra- the content of sodium ion, and the results can be displayed in
uterine pressure. At this moment, the intrauterine pressure 2 min. This type of equipment is applicable to the monitoring
must be controlled below 100 mmHg, the amount of inflow of operative hysteroscopy, which not only can provide the
and outflow of irrigation fluid should be accurately recorded, levels of plasma electrolyte during operation, but also can
and the surgical treatment should be terminated as quickly as guide the treatment of dilutional hyponatremia.
possible (Table 12.7). Compared with electrolyte distention media, the thresh-
In hysteroscopic surgery, the balance of fluid can be main- old value for water intoxication of electrolyte-free media is
tained by measuring the inflow and outflow of the distention relatively low. It is very important to record accurately the
fluid in a variety of ways. For example, 1% of ethanol is put amount of inflow and outflow of the fluid during operation.
into the distention fluid, and the ethanol content in the col- When the fluid deficit of inflow and outflow is ≥1 L, the
lected outflow fluid is measured through a special breath concentration of electrolyte (Na+) in blood should be imme-
analyzer, thus in vivo absorption volume can be indirectly diately detected, and diuretics should be given and intrave-
nous rehydration of solution containing electrolyte, the
Table 12.5 The content and energies of sodium chloride in electrolyte anesthesiologist should cooperate actively with the full range
media (approximate values) of intensive care, especially for patients under general anes-
Energies Na+ Cl− thesia, such as the measurement of oxygen saturation and
Solutions (cal) (mmol/L) (mmol/L) esophageal temperature, and the monitoring of various vital
0.45% sodium chloride – 77 77 signs and urinary output (Tables 12.8, 12.9, and 12.10).
5% glucose with 0.45% 170 77 77
NaCl
10% glucose with 0.45% 340 77 77
NaCl 12.2.3 TURP Syndrome
Normal saline(0.9% – 154 154
NaCl) TURP syndrome is a series of symptoms and signs caused by
5% glucose with 0.9% 170 154 154 large amount absorption of electrolyte-free irrigation fluid
NaCl when monopolar hysteroscopic resection is performed.
10% glucose with 0.9% 340 154 154
Patients first present with slow heart rate and increased blood
NaCl
3% sodium chloride 513 513 pressure, then followed by decreased blood pressure, nausea,
solutiona vomiting, headache, blurred vision, anxiety, mental disor-
5% sodium chloride 855 855 ders, and lethargy. These symptoms are induced by increased
solutiona blood volume, dilutional hyponatremia, and decreased
a
Hypertonic solution, which is not generally used in intravenous plasma osmotic pressure. If diagnosis and treatment are not
injection
Table 12.6 The energies and the contents of ion in balanced solution
Solutions Energies (cal) Na+ (mmol/L) Cl− (mmol/L) K+ (mmol/L) Ca2+ (mmol/L) Lactate
Lactated Ringer’s solution (HARTMANN’S) 9 130 110 4 1.5 28
5% glucose-containing Ringer’s solution 179 130 110 4 1.5 28
5% glucose + 20 KCI Ringer’s solution 179 130 129 24 1.5 28
5% glucose + 40 KCI Ringer’s solution 179 130 149 44 1.5 28
374 E. Xia et al.
Table 12.7 Factors influencing uterine distention media into blood timely, convulsions, cardiovascular failure, or even death
circulation may also occur. This syndrome has been familiar to doctors
Type of media: CO2, Hyskon solution, low-viscosity distention of urology and anesthesiology. In hysteroscopic operation,
media
for female patients, especially in the period, the functional
Intrauterine pressure > mean arterial pressure; depth of myometrial
resection >4 mm
disorders of ATP enzyme in the brain may cause a drop in
Operating time >1 h their own capacity to regulate drainage, so if the timely diag-
Amount of irrigation fluid consumption nosis and treatment are not given at the onset of TURP syn-
Hysteroscopic operation without fluid outflow channel or without drome, its risks and the likelihood of death will increase
continuous fluid pump apparently. However, because the human brain itself is able
Blockage of fluid outflow channel to regulate body fluid balance and prevent the excess fluid
The irrigation fluid cannot flow out due to the tight cervical orifice absorption and hyponatremia, which manifests clinically as
Type of surgery: incision exceeds the middle layer of myometrium,
reaches serosa, or forms partial uterine perforation
slow development, usually the symptoms may appear after
Excessive uterine fluid irrigation 48 h. Therefore, clinically, doctors should be wary of hypo-
natremia, and once symptoms appear, positive treatment
should be implemented. Notably, one must be careful of
Table 12.8 Prevention of fluid overload during TCRM
intravenous infusion of sodium, and remember the intrave-
Discussion with the anesthesiologist: the complexity of operation, nous infusion of sodium should not be given fast and in a
intraoperative venous infusion, and complications that may occur
Epidural anesthesia should be considered for patients at high risk
high concentration so as not to cause a temporarily low
Indwelling catheter for monitoring of the urinary output osmotic pressure inside the brain, which may transfer the
The fluid deficit between inflow and outflow should be accurately brain interstitial fluid to the blood vessels, causing brain tis-
estimated sue dehydration, thus leading to brain damage.
Observation of decompensation signs, including the change in vital In acute period of hyponatremia, the replacement of sodium
signs, decrease in oxygen saturation, drop in temperature (taken by at a rate of hourly increase in osmotic pressure by 1–2 mOsm/L
esophageal probe), and abnormal ECG
can alleviate the symptoms, but the total increased plasma
The fluid deficit of inflow and outflow is >800 mL: detecting serum
electrolyte (Na+) level, and comprehensively considering the osmotic pressure must not exceed 12 mOsm/L within 24 h. In
operative process and the patient’s condition addition, the patients still need special care like continuous
The fluid deficit between inflow and outflow is >1000 mL: if the monitoring of plasma electrolyte concentrations and urinary
serum electrolyte (Na+) level decreases, the signs of functional output. Usually, the hypertonic saline solution should not be
metabolic disorder appear, and the operation cannot be completed
in a short period of time, the operation should be terminated used in the correction of hyponatremia, but replacement of
normal saline will be extremely effective, and clinical symp-
toms can generally recover within 12–24 h.
Table 12.9 Relationship between the absorption of 1.5% glycine and
the decrease of serum sodium levels
Based on the above reasons, if it is estimated that more
tissues will be excised during operation, the regional block
Fluid deficit (mL) Decreased value of serum sodium (mmol/L)
anesthesia should be chosen to keep the patient awake so that
<500 0–2.5
=500 4–5 the doctor may discover timely the early symptoms of water
=1000 8–10 intoxication such as obnubilation, tremor, nausea, and
=2000 16–20 headache.
>2000 >20 In the corrective treatment of patients with hyponatremia,
the blood sodium concentration should not be made to return
Table 12.10 Treatment of fluid overload during operative rapidly to normal in a rush. The serum sodium levels should
hysteroscopy be just maintained in such an extent that no serious second-
Decreased value ary complications may occur.
of serum sodium Fluid deficit Five cases with TURP syndrome had been treated in the
(mmol) (mL) Principles of treatment Hysteroscopy Center of Fuxing Hospital, Capital Medical
0–5 ≤500 No need for treatment University, with the occurrence and treatment seen in
8–10 =1000 Close monitoring (testing serum Table 12.11.
sodium and using diuretics)
16–20 =2000 Stop the operation (dynamic
observation of serum sodium,
sodium replacement, and 12.2.4 Prevention of TURP Syndrome
diuresis)
>20 >2000 ICU (consultation, sodium 1. The preoperative treatment of uterine cervix, endome-
(warning replacement, and diuresis)
value, may trium, and uterine myomas contributes to the reduction of
cause death) irrigating fluid absorption.
12
Table 12.11 Occurrence and treatment of TURP syndrome in five cases

Serum sodium at
Fluid volume/deficit the end of surgery
No Operations Duration (min) (mL) Clinical manifestation (mmol/L) Treatment
1 TCRE for DUB 40 21,000/1500 Lethargy, apathy, dullness 130 Intramuscular injection of furosemide 20 mg
and quick intravenous injection of saline
1000 mL. The serum sodium returns to normal
16 h later
2 TCRM for 6.4 cm 100 32,000/2000 Lethargy, apathy, dullness, facial 122 Intramuscular injection of furosemide 20 mg
pedunculated submucous swelling, headache twice and quick intravenous injection of saline
myoma 1500 mL. The serum sodium returns to normal
24 h later
3 TCRM for 4 cm inward- 80 6000/no result Lethargy, facial swelling, 125 Intramuscular injection of furosemide 20 mg,
protruding intramural myoma dizziness, headache, nausea quick intravenous injection of 3% sodium
with total resection (100%) chloride 100 mL, and normal saline
1000 mL. The serum sodium returns to normal
15 h later
4 TCRM for 4.4 cm inward- 55 4000/2000 – 128 Quick intravenous injection of furosemide
protruding intramural myoma 20 mg and normal saline 1000 mL. The serum
with 80% resected sodium returns to normal 4 h later
5 TCRM for two 3 cm 45 6000/2500 Dysphoria, pink frothy sputum, 105 Quick intravenous injection of furosemide
submucous myomas resected chest rales, heart rate 138 times/ 20 mg, 10% sodium chloride 40 mL, and
completely, and one 4.4 cm min, nasal flaring, indifference, deslanoside 0.4 mg. Facemask supply of oxygen
inward-protruding intramural oxyhemoglobin saturation 84% and inhalation of 50% ethanol. The serum
myoma with 20% resected sodium is 125 mmol/L 4 h later and reaches
130 mmol/L after another 4 h following
intravenous injection of furosemide 20 mg
375
376 E. Xia et al.
2. The low-pressure irrigation should be taken on the prem- Table 12.12 Scoring criteria for high-risk fluid overload prior to EA
ise of a clear vision. Score 0 1 2 3
3. To the patients without contraindications, intracervical Parous women Yes – – no
injections of a dilute pituitrin solution (pituitrin 10 u + 80 mL Endometrial pretreatment Yes No – –
normal saline) at 3 and 9 o’clock positions around the cer- Length of uterine cavity (cm) <8 8 9–10 >10
vix can cause strong uterine contraction which maintains at Coexistence with submucous myoma No – – Yes
least 20 min. Corson et al. reported that intracervical injec-
tion of vasopressin resulted in a threefold decrease in fluid Table 12.13 Scores for high-risk fluid overload during TCRE (fluid
absorption when compared with placebo group. absorption > 1 L)
4. Excessive resection of uterine myometrial tissues should Minor risk 0–2
be avoided. The intrauterine pressure should be controlled Moderate risk 3–7
below 100 mmHg and should not exceed the mean arte- Severe risk ≥8
rial pressure (MAP) levels; the operating time should not
exceed 1 h. If the operation lasts more than 30 min, an sues, for example, resection of submucous myoma with
intravenous injection of furosemide 20 mg can be given. broad pedicle, resection of the endometrium, incision or
5. The fluid deficit in irrigation fluid should be closely mon- excision of large uterine septum, large areas of intrauterine
itored. If it amounts to 1000–2000 mL, the operation adhesions, etc.
should be ended as soon as possible; if >2000 mL, the In this type of operation, if the amount of fluid absorption
operation must be immediately stopped, and electrolyte is more than 1 L, specialized scoring criteria can be used for
concentration in blood should be detected. the assessment of fluid overload. Molnar et al. developed a
set of scoring criteria for patients with intraoperative fluid
absorption of more than 1 L during TCRE (Tables 12.12 and
12.2.5 Treatment of TURP Syndrome 12.13), in which the final overall score is a very important
index. Through assessment of this score, it is very helpful for
1. If the postoperative serum sodium concentration is the physicians to understand the overall situation of patients.
between 130 and 140 mmol/L, no treatment is needed. It is worth stating that the operation in a larger uterine cavity
2. If the postoperative serum sodium concentration drops to makes it possible to prolong the operating time and if it is
120–130 mmol/L, intravenous injection of furosemide resection of larger submucosal myoma, not only the operat-
10–20 mg can be administered and the intake of liquid ing time is longer but also the deep layer of uterine muscle
should be limited. The amount of fluid into and out of the wall may be resected, and operation difficulty can be
body should be carefully recorded, and the serum sodium increased even without endometrial pretreatment, A long-
concentration is detected once every 4 h until it exceeds term use of GnRH-a can constrict the endometrium and
130 mmol/L. myometrial vessels and reduce the amount of intraoperative
3. If the serum sodium concentration is below 120 mmol/L, irrigation fluid absorption.
the treatment with hypertonic saline is required and care-
ful care is taken.
4. For the patients with overt encephalopathy, no matter 12.2.7 New Operative Device: Imitated Bipolar
how much the serum sodium concentration is, the treat- System
ment with hypertonic saline shall be prescribed.
5. Hypertonic saline therapy: It can be seen in detail in Sect. The advent of operative electrode in the electrolyte solution
9.2 of Chap. 9 about the treatment of hyponatremia. has attracted the great attention of endoscopic doctors. This
electrode is not true bipolar coagulation electrode, but its
Kumar and Kumar reported that, during hysteroscopic principle is similar to that of bipolar coagulation system. The
surgery, procedures were stopped for 10 min with no inter- electric current flows from one side to the other and the tis-
vention of glycine irrigation, which reduced the fluid absorp- sues between the electrodes are destroyed by a form of
tion by 67% (38.75–85.81%). It might be due to blood clots vaporization through increased electric current density when
sealing the open blood vessels which prevented further operated, like the Versapoint system, which is currently used
absorption of distending medium. in clinical practice. It is worth mentioning that in hystero-
scopic operation with the electrolyte liquid as distending
medium, if there is no monitoring of the liquid, there will be
12.2.6 Monitoring Device for the Prevention excessive electrolyte fluid absorption, and it is still possible
of Fluid Overload (Portable) to induce pulmonary edema. And when a lot of electrolyte
solution is in use and no attention is paid to monitoring the
During hysteroscopic operation, fluid overload often occurs urinary output, the patients may excrete large volumes of
in the resecting or destroying large areas of myometrial tis- hypertonic urine with sodium and potassium, resulting in the
so-called desalination. Meanwhile, the water accumulated in 12.3 Intra- and Postoperative Bleeding
the microcirculation not only can induce pulmonary edema,
but also may cause delayed hyponatremia. In patients with Dan Yu
the isotonic saline solution in use, this will eventually lead to
delayed hyponatremia and even death. Therefore, when elec- Bleeding complication of hysteroscopic surgeries is defined
trolyte liquid is used in distending uterine cavity with con- as hemorrhage with the amount being much more than that
tinuous monitoring system, the amount of inflow and outflow of normal blood loss during operation and in early or late
of irrigation fluid must be closely monitored, and the amount postoperative period. Some measures are necessary to be
of fluid absorption may be calculated according to the fluid taken to control the bleeding.
deficit. If the amount of distention media absorption has In the early stage of hysteroscopic applications, intra- and
reached the limiting value, operation should be immediately early postoperative bleeding was reported as the second most
stopped. To the patients who have electrolyte fluid absorp- common complication of hysteroscopic surgeries, just fol-
tion over 1.5–2 L, diuretic therapy should also be timely lowing uterine perforations. Jansen et al. made a summary of
administered. 13,600 procedures of both hysteroscopy and hysteroscopic
surgeries. The results showed that bleeding complication
occurred in 22 procedures (0.16%), with all being associated
12.2.8 Conclusion with perforations. Agostini et al. studied 2116 hysteroscopic
surgeries and found hemorrhage in 13 (0.61%). According to
There is no doubt that great progress has been made in hys- the data collected by the Hysteroscopy Center of Fuxing
teroscopic techniques during the past 20 years, and a large Hospital, Capital Medical University, between January 1995
number of gynecological doctors have been constantly and January 2001, there were 1747 cases of hysteroscopic
improving their operating skills, and constantly developing procedures, in which, bleeding complications occurred in five
and broadening new areas of treatment with operative hys- (0.29%). It was believed that, in all types of hysteroscopic
teroscopy. The fantastic development of technology has surgery, the highest risk of bleeding occurred in the resection
greatly driven the endoscopic manufacturing enterprise to of uterine myomas, especially inward-protruding intramural
develop and produce hysteroscopy instrument with superior myomas, with the occurrence rate reaching 2–4%. It was fol-
performance and its corollary equipment, particularly the lowed by endometrial ablation with electroresection, Nd-YAG
advent of the hysteroscope with continuous irrigation and laser, or rollerball coagulation. In addition, bleeding might
the hysteroscopic resectoscope makes intrauterine electro- also occur during the resection of septum, or in cases with
surgery possible. Clinical practice has proved that low-vis- injuries to cervix and lower part of the uterine cavity.
cosity liquid has become the main distention media in Along with the development of hysteroscopic technology,
operative hysteroscopy due to its advantages of good circu- the occurrence rate of bleeding complications in routine hys-
lation and clear vision. The electrolyte media can be used teroscopic surgeries decreased significantly. But in some dif-
with any intrauterine operation except with intrauterine ficult hysteroscopic surgeries, such as operations on cornual
electrosurgery. However, regardless of the use of electrolyte pregnancy, cervical pregnancy, scar pregnancy following
or electrolyte-free media, prolonged intrauterine operation cesarean section, cervical myoma, and inward-protruding
may cause excessive fluid absorption, and excess absorption intramural myoma, etc., the occurrence rate of intra- and
of low-viscosity electrolyte-free solution at early stage can postoperative bleeding was higher.
induce pulmonary edema and hyponatremia. Therefore,
during the operation, it is very important to monitor closely
the volume of inflow and outflow of uterine distention 12.3.1 Factors and Mechanisms of Intra-
media, and the volume of liquid inflow and outflow must be and Postoperative Bleeding
recorded accurately so as to avoid the fluid deficit to be
increased. At the same time, anesthesiologists, nurses in the 12.3.1.1 The Cutting Depths of TCRE, TCRA,
operating room, and the operators should cooperate closely and TCRP Reaching the Uterine
and always be alert to avoid excessive fluid absorption. Vascular Layer
Once the sign of the fluid overload appears, early diagnosis The uterus is a highly vascular organ with rich blood vessels
and timely treatment should be given so as to avoid serious in its muscle wall. Its vascular layer is located 5–6 mm
consequences. The specialized standard procedures for hys- underneath the endometrial layer, which is approximately
teroscopic surgery should be established, which is of great 1/3 of the uterine muscle wall with more blood vessels run-
significance for early diagnosis and proper treatment of ning through. The cutting depths of TCRE, TCRA, and
intraoperative fluid overload so as to avoid severe TCRP are usually above the vascular layer; therefore, mas-
complications. sive bleeding may occur when cutting reaches this layer.
378 E. Xia et al.
12.3.1.2 Bleeding from the Myometrium contraction of the uterus may occur when the hysteroscopic
of the Fundus Because of the Injury resection is too deep, which leads to massive bleeding.
of the Vessels When TCRS Reaches
the Fundus 12.3.1.5 Disturbed Contractility of the Uterus
When the resection of TCRS gets to the fundus, heavy bleed- with Adenomyosis or Myoma
ing will be caused if the cutting is so deep that it reaches the Uterine adenomyosis or myomas can disturb uterine contrac-
vascular layer of the fundus, or perforation of the fundus tility. Poor contractility will lead to more bleeding during
occurs and damages the vessels of the uterine walls. intraoperative and early postoperative period when hystero-
scopic surgery is performed for intrauterine lesions.
12.3.1.3 Bleeding from the Base of Myomas
with Large Size and Special Location 12.3.1.6 Uterine Arteriovenous Fistula
In hysteroscopic resection of large myomas, type II submu- Uterine arteriovenous fistula is the connection of vascular
cous myomas, inward-protruding intramural myomas, or walls between uterine artery and veins resulting from abnor-
intramural myomas adjacent to the uterine cavity, because of mal development and proliferation of uterine vessels due to
their deep location, large vessels are easily damaged when congenital or acquired factors, which causes the formation of
the resection approaches or reaches the base of the myomas. fistula. Massive bleeding might happen when arteriovenous
In such occasions, hemostasis will be very difficult. If the fistula in uterine walls is damaged by hysteroscopic
myometrial wall at the base of myomas is very thin, it will be operations.
difficult to contract after resection, so the bleeding will be
hard to stop. If the resection penetrates the walls at the base, 12.3.1.7 Coexisting with Relevant Medical
which leads to perforation, massive bleeding will be caused. Diseases
Another type of myoma with special locations is cervical If the patients are concurrent with dysfunctional diseases of
myoma. If the resection on cervical lateral walls is too deep blood coagulation, such as blood disease, severe damage of
during the procedure, the descending branch of uterine artery liver function, hepatocirrhosis, renal failure, and long-term
will be damaged and massive bleeding will be caused. usage of anticoagulant after cardiac valve replacement, etc.,
the bleeding during hysteroscopic procedures is difficult to
12.3.1.4 Bleeding from the Damaged Vessels control.
During Hysteroscopic Operations
on Intrauterine Conception in Special
Locations 12.3.2 Intraoperative Bleeding
Intrauterine conceptions in special locations include cornual of Hysteroscopic Surgeries
pregnancy, cervical pregnancy, cesarean scar pregnancy, etc.
In women with cornual pregnancy, the uterine cornu is 12.3.2.1 Identification of Intraoperative
enlarged due to conception. The myometrial walls in this Bleeding
area are filmy and plenty of blood supply, with large vessels For experienced gynecologists, massive intraoperative bleed-
visible. So when performing the hysteroscopic operation, it ing during hysteroscopic operation is very rare. The conven-
is easy to damage the vessels or get perforations, which will tional cutting depth of TCRE is 2–3 mm underlying
lead to massive bleeding. endometrium, which is deep enough to resect the full endo-
The cervix mainly contains connective tissues, with little metrial layer except for adenomyosis and not cut larger ves-
musculature and filmy cervical walls, therefore the cervical sels. The vessels underneath the endometrium are so small
contractility is poor, and the opened vessels are not easy to that the resection cannot cause bleeding. Secondly, when
be occluded. Therefore heavy and continuous bleeding is cutting, the blended cutting current involving coagulation
very prone to occur during hysteroscopic operation on cervi- current may close small vessels. Furthermore, the irrigation
cal pregnancy. fluid may cause an increase of intrauterine pressure, which
In cases with scar conceptions following cesarean sec- forms the forces against vascular bleeding, thus reduces the
tion, the probability of injury, which occurs during hystero- bleeding from veins. So operations of TCRE can be regarded
scopic procedures, is very high because of the filmy walls at as “non-bleeding” procedures.
the location of conception. Moreover, it is difficult to stop When compared with TCRE, the amount of blood loss
the bleeding because of the poor elasticity and low contrac- during TCRM increases greatly. Yu et al. carried out a study
tility of the myometrium here. and found that the volume of intraoperative bleeding was at
In addition, in cases with the implantation of pregnant tis- an average of 17 mL in hysteroscopic resection of small
sues into uterine myometrium, uterine perforation or poor myomas (no more than 3.5 cm in diameter), and at an aver-
age of 64 mL in large myomas (more than 3.5 cm in

diameter).
A great volume of bleeding may take place when the vas-
cular layer is damaged due to too deep resection into myo-
metrium during hysteroscopic operations; when bigger
vessels are damaged by electroresection in cases with big
and deep myomas in uterine cavity; when the vessels in uter-
ine walls are damaged due to the perforation of the uterus
occurring during hysteroscopic operations; when large ves-
sels are damaged by resection in the uterus with plenty of
blood supply due to conception; when uterine arteries at the
level of lateral cervical walls are damaged and perforation
occurs during operations in cases with cervical lesions; and
when the fistula is damaged by hysteroscopic operations in
cases with uterine arteriovenous fistula.
Too much bleeding from the cutting surface during opera-
tions can seriously interfere with the vision of operating
field, which results in difficult operation of hysteroscopy and
prolongation of operating time. The occurrence rates of other
complications such as fluid overload are increased
correspondingly.
12.3.2.2 Prevention and Treatment Fig. 12.3 When the resection reaches the uterine fundus during TCRS,
active bleeding is visualized and coagulated by hysteroscopic needle
of Intraoperative Bleeding electrode
1. Pretreatment of medication before surgery: Many studies
indicated that pretreatment of medication before hystero-
scopic surgeries may lead to a thinning of endometrium
and decrease of vascularizations, which reduces intraop-
erative bleeding. Cooper et al. held that preoperative
administration of oral contraceptives or GnRH analog for
a period can reduce intraoperative bleeding and help to
correct anemia.
2. Intraoperative coagulation for hemostasis: For intraoper-
ative bleeding of hysteroscopic surgery, if there is evident
bleeding point, the bleeding vessels can be coagulated by
electric loop electrode, and rollerball or roller cylinder
electrode with the coagulation current at 40–60 W, there-
fore the bleeding can be arrested effectively (Figs. 12.3
and 12.4). If there is bleeding from fibroid, electrocoagu-
lation of blood vessels may be performed around the
pseudocapsule (Fig. 12.5).
3. Hemostasis by increasing the pressure distending the cav-
ity: By increasing the distending pressure appropriately,
the irrigating fluid in uterine cavity can press on the
denuded broken vessels in uterine cavity to achieve
hemostasis. However, it should be noted that increase of
the distending pressure of the cavity and the rapid absorp-
tion of irrigating fluid can result in dilutional Fig. 12.4 An active bleeding is seen on lateral wall of uterine cavity
hyponatremia. during TCRE, which is stopped by coagulation with loop electrode
380 E. Xia et al.
4. Decrease of intrauterine pressure, inspection of bleeding with high approach starts from lateral pelvic wall (the
point, and coagulation to stop bleeding at the end of sur- anterior leaf of the broad ligament), dissects the internal
gery: Before the operation comes to an end, the distend- iliac, and then identifies the origin of the uterine artery,
ing pressure may be reduced, which permits the
visualization of bleeding from broken vessels on the sur-
face of the cavity. Thus it is necessary to search for the
bleeding points carefully under hysteroscopy and then to
coagulate for precise hemostasis in conditions of pulse
arterial bleeding (Figs. 12.6 and 12.7).
5. Intrauterine balloon tamponade for hemostasis: If there is
blood oozing at the end of the operation, especially in
operations with myoma resections, a Foley catheter can
be inserted into uterine cavity and 10–30 mL of fluid may
be introduced into the balloon. The balloon is kept in
place for 6–8 h, which can generally achieve a good
hemostasis (Fig. 12.8). In the Hysteroscopy Center of
Fuxing Hospital, Capital Medical University, there have
been three cases of intraoperative bleeding irresponsive
to general management, and their treatment is seen in
Table 12.14.
6. Prophylactic uterine artery occlusion: Laparoscopic uter-
ine artery occlusion (LUAO) is a procedure that bilateral
uterine arteries are blocked via laparoscopic approach. For
hysteroscopic surgeries with high risk of bleeding, LUAO
may be performed prior to the hysteroscopic operation,
which can reduce the flow of blood, decrease intraoperative
bleeding, make the vision of operations clear, lower the Fig. 12.6 Before the end of TCRE, the pressure in uterine cavity is
difficulty of procedures and improve its safety. reduced to inspect the cutting surface. Active bleedings are seen on pos-
According to different routes and regions of uterine terior wall and coagulated by loop electrode
artery occlusion, LUAO is classified into high and para-
uterine approaches to occlude the uterine arteries. LUAO
Fig. 12.7 Before the end of TCRE, the surface in uterine cavity is
Fig. 12.5 During hysteroscopic resection of myomas, active bleedings inspected. The active bleedings on posterior wall of uterus are coagu-
are seen on cutting surface of pseudocapsule lated with PlasmaButton vaporization
which is the first branch of internal iliac. The origin of teroscopic surgeries. Isaacson reported that postoperative
uterine artery is isolated and coagulated to achieve occlu- bleeding was more common than intraoperative bleeding
sion. This approach is also named lateral approach and is because of the drops of intrauterine pressure at the end of
a more commonly used occlusion method in clinic so far. hysteroscopic procedures. In fact, there is a small volume of
LUAO with parauterine approach opened the anterior or bleeding after almost all of the hysteroscopic surgeries. It
posterior leaves of broad ligament at the level of cervical was reported that the amount of postoperative blood loss was
internal os, the uterine artery is identified, isolated, and about 30 mL within 24 h after TCRE and was 20–80 mL
then coagulated for occlusion. within 24 h after TCRM. In conditions that the amount of
7. Management of original medical diseases: In patients bleeding is still significant at the end of procedures, some
with concurrence of dysfunctional diseases of blood measures of hemostasis should be taken before the patients
coagulation, some measures should be taken pre- or post- leaving the operating room.
operatively to decrease the occurrence of bleeding com-
plications. These measures include the management of 12.3.3.2 Prevention and Treatment of Bleeding
the original medical diseases, evaluation and adjustment in the Early Postoperative Period
of the coagulation functions, preparation of intraoperative 1. Mechanical tamponade with Foley balloon for
medications, and close monitoring during operations. hemostasis
Pressing hemostasis by local tamping has been used
for a long time in first aid for trauma and surgical opera-
12.3.3 Bleeding in the Early Postoperative tions. Balloon tamponade for hemostasis has been applied
Period in transurethral resection of the prostate and treatment of
esophageal varicose. In 1981, Goldrath first introduced
12.3.3.1 Identification of Bleeding in the Early the Foley balloon tamponade into the fields of hemor-
Postoperative Period rhage in gynecology and gynecological endoscopic sur-
It is generally believed that bleeding in the early postopera- gery. In a case of laser endometrial ablation with 5%
tive period refers to the hemorrhage within 1 week after hys- glucose saline as a uterine distending medium, heavy
hemorrhage of the uterus was observed when the proce-
dure was coming to an end. After intrauterine insertion of
a Foley catheter and balloon inflation with saline injec-
tion, the hemorrhage was arrested immediately.
(a) Mechanisms of Foley balloon tamponade for
hemostasis
Application of Foley balloon tamponade can
mechanically compress the uterine walls and press
on the opened vessels from cutting surfaces to
achieve hemostasis. Through X-ray observation with
an intra-balloon injection of a contrast agent,
Goldrath also discovered that the shape of the uterine
cavity and the shape of the balloon were adapted to
each other, and their adaptability depends on the size
of the uterine cavity and the size of the balloon,
Fig. 12.8 The balloon of a Foley catheter is inflated to achieve tam-
ponade of the cavity respectively. Goldrath also conducted a research on
Table 12.14 Characteristics and managements of intraoperative bleeding in three cases with hysteroscopic surgeries
No. Details in operations Blood loss (mL) Clinical manifestations Managements
1 TCRM for a 5-cm broad pedicle submucous 700 Dropping in blood pressure Immediate laparotomy and
myoma with massive intraoperative bleeding. removal of the uterus
Extremely poor contraction of the uterus at the
end of the operation led to ongoing bleeding
2 At the end of TCRP, the uterus bled without 200 (–) Bleeding stopped after
stopping, with poor response to oxytocin balloon tamponade for 4 h
3 TCRM for a 6.5-cm intramural myoma 200 (–) Bleeding stopped after
(inward-protruding extension 30%). Sevent balloon tamponade for 9 h
percent of the myoma was resected, with poor with 120 mL of blood loss
hemostasis in the base of the myoma
382 E. Xia et al.
the possibility of bleeding flowing in reverse through catheter, and then the tip of the catheter above the
the fallopian tube. He concluded that the intrauterine balloon is cut off with scissors (Fig. 12.9). It
balloon produced enough pressure to compress on should be careful not to cut and break the balloon.
the uterine cornua, and the blood clots might obturate Cutting off the top of the catheter above the bal-
the fallopian tubal ostia. So whatever the conditions loon can make the intrauterine balloon globular,
are, there was little volume of blood in the interstice and therefore in close contact with the uterine
of uterine cornua flowing in reverse through the nar- walls, so the balloon can produce a uniform com-
rowed fallopian tubal canal. From other clinical pression on uterine walls.
observations, it was also confirmed that no case of • At the end of operation, a Foley catheter is inserted
intraabdominal hemorrhage occurred when using into the uterine cavity. The Balloon is inflated
balloon tamponade for hemostasis. Foley balloon with appropriate amount of sterile saline solution
tamponade for hemostasis is a simple, effective, and so that it cannot prolapse when it is pulled gently
low-cost treatment and does not need to conduct spe- downwards. Vaginal bleeding is observed simulta-
cial technologies. It has gradually became one of the neously (Fig. 12.10a, b).
most commonly used methods for prevention of post- • The end of the catheter is connected with a collect-
operative hemorrhage. ing bag to gather and evaluate the intrauterine
(b) Procedures of Foley balloon tamponade for bleeding.
hemostasis • The Foley catheter is kept in situ for 6–8 h and
• A double channel Foley catheter is applied. One to removed later.
3 mL of gas is firstly injected into the balloon to • Antibiotics are routinely given to prevent
indicate the border between the balloon and the infections.
Fig. 12.9 The balloon of a double channel Foley catheter is inflated with 3 mL of a gas to indicate its borderline, and then the tip of the catheter
above the balloon is cut off
a b
Fig. 12.10 Foley balloon tamponade. (a) At the end of operation, a Foley catheter is inserted into uterine cavity. (b) The balloon is inflated with
sterile saline to achieve hemostasis
(c) Precautions removed after graded withdrawing of the fluid in

• The volume of fluid injection into the balloon: The balloon and decreasing of its pressure. In cases of
normal capacity of uterine cavity is 5–10 mL. The using balloon tamponade, if bleeding still exists in
volume of fluid injection is between 10 and 20 mL uterine cavity, it can usually be drained away
based on the volume of the cavity and the size of along the vagina or a Foley catheter. When the
the myoma. In cases with heavy bleeding due to a balloon is kept in situ, if the bleeding gets
larger uterus and bigger myomas, the balloon can increased, additional measures may be conducted,
be inflated with 15–30 mL of fluid injection. such as supplementary injection of fluid into the
Professor Lin from Japan believed that in cases of balloon to increase the intrauterine pressure for
hysteroscopic resection of myomas, the volume of hemostasis, suturing of the uterine cervical os
fluid introduced into the balloon should be less with silk sutures applied for hemostasis, or pulling
than the weight of the excised myomas. By ultra- outward of the balloon catheter to increase the
sonography scan, the size of the balloon should be pressure on bleeding from cervical canal. There
smaller than that of myomas prior to surgery were also reports on myometrial necrosis result-
(Fig. 12.11a, b). If the balloon tamponade still ing from prolonged insertion of the balloon, which
cannot stop bleeding, it is mostly because of insuf- supported the idea that the duration of balloon
ficient injection of fluid into the balloon. In this tamponade cannot be too long.
situation, more additional injection or silk sutur- • In cases with small amount of bleeding, sufficient
ing of the uterine cervical os may be adopted to hemostasis can be achieved by vaginal insertion of
increase the intrauterine pressure for hemostasis. sterile gauze. In cases with larger amount of
In addition, hemorrhage from cervical canal can bleeding, a Foley balloon intrauterine tamponade
be compressed by pulling the balloon catheter for hemostasis can be conducted. In cases with a
outward. At the time of withdrawing the balloon big uterine cavity and heavy bleeding, two balloon
catheter, the sutures of cervical os should be catheters can be introduced into the cavity to
removed at the same time. increase the intrauterine pressures or to compress
• Duration of balloon tamponade: In general, the the upper and lower parts of the cavity separately.
duration of intrauterine balloon tamponade is 2. Medications for hemostasis
from 6 to 8 h. Prolonged and high-pressure bal- During hysteroscopic surgeries, medications such as
loon tamponade may cause avascular necrosis of vasopressin and prostaglandins are also commonly used
endometrium or even of uterine walls. The Foley for local hemostasis.
balloon can be completely removed 6–8 h later or (a) Vasopressin (VP)
a b
Fig. 12.11 Transabdominal longitudinal ultrasonography scan. (a) diameter. (b) After TCRM. A Foley catheter is inserted into the uterine
Before TCRM. The uterus is in anteversion, and a type II submucous cavity, and the balloon is inflated with 30 mL of normal saline
myoma is located in posterior wall of the uterine cavity with 4 cm in
384 E. Xia et al.
In order to prevent and control acute or massive sudden heavy bleeding. In this situation, hysteroscopy
bleeding, natural or synthetic vasopressin has been can be performed to identify the active bleeding on the
used as a vasoconstrictor in gynecologic surgeries for surfaces in both cervical canal and uterine cavity.
a history of nearly 100 years. Pharmacological doses Coagulation of these bleeding points under hysteroscopy
of vasopressin can cause the contractions of smooth may achieve an effective hemostasis.
muscles in gastrointestinal tract, uterus, and all vascu- 4. Uterine vascular occlusion and hysterectomy
lar beds, especially the muscles in capillaries, arteri- If various methods of hemostasis are ineffective after
oles, and venules. However it has weak effect on hysteroscopic surgery, emergency treatments such as
smooth muscular tissues in large vessels. Vasopressin uterine vascular occlusion or hysterectomy should be
injection is a water-soluble synthetic vasopressin considered. Uterine vascular occlusion mostly includes
(8-l-arginine vasopressin) with half-life of 10–20 min. uterine artery embolization and transvaginal or laparo-
Cervical injection with diluted vasopressin can cause scopic uterine vascular occlusion. Uterine artery emboli-
contraction of the uterus for hemostasis. Yet many zation is a procedure of selective blockage of the arteries
scholars believed that the administration of exoge- with different substances to block the blood flow, which is
nous vasopressin could increase the abnormal secre- mainly used in acute uterine hemorrhage. Transvaginal
tion of antidiuretic hormone induced by the operative uterine vascular blockage is transvaginal ligation of both
stress, which might increase the morbidity of dilu- uterine arteries and ovarian arteries so that the blood flow
tional hyponatremia and exacerbate the symptoms. of the uterus can be reduced to achieve hemostasis.
Philips et al. carried out a study on the effects of Laparoscopic ligation of uterine vessels coagulates and
preoperative cervical injection with 20 mL dilute blocks the uterine arteries under laparoscopy, which
vasopressin solution (0.05 U/mL) or placebo in 106 decreases the blood flow of the uterus promptly, so that
patients who received hysteroscopic surgeries. The the uterine bleeding can be controlled effectively.
results showed that, in a group of patients receiving If all of the above treatments of bleeding have failed to
cervical injection with vasopressin solution, when achieve hemostasis, transabdominal or laparoscopic hys-
compared with that in placebo group, the amount of terectomy can be conducted. With the development of
intraoperative blood loss was significantly decreased, medical technology, a range of conservative therapies can
the volume of distending fluid absorption was greatly be taken to control the uterine bleeding effectively, which
reduced, and the operating time was largely short- reduces the use of traumatic operations. There were four
ened. Furthermore, there were no significant differ- cases of postoperative bleeding that occurred in the
ences between the two groups of patients in cardiac Hysteroscopy Center of Fuxing Hospital, Capital Medical
contractility, blood pressure, heart rate, or rhythm of University. Their treatment process is shown in
the heart. However the vasopressin has life- Table 12.15.
threatening cardiovascular effects and may induce
some serious complications, so the indications of its
application must be strictly controlled in patients 12.3.4 Bleeding in the Late Postoperative
who have endometrial ablation and resection of Period
myoma with the size smaller than 3 cm. Robert et al.
studied the effects of preoperative paracervical injec- Sometimes, there are patients who have massive bleeding at
tion of adrenaline in patients with TCRE. They con- 1 week after operation and are referred to hospital again. In
cluded that it could decrease the amount of intra- and addition to intrauterine insertion of balloon catheter, suturing
postoperative bleeding and reduced the application of the cervical os may be applied for hemostasis. Estrogen
of balloon tamponade in the uterine cavity, but the and antibiotics should be given simultaneously to promote
routine use of it was restricted because a few patients the repair of endometrium and prevent the infections. In
developed paroxysmal tachycardia (>110/min). clinic, this situation is uncommon. Some patients may have
(b) Prostaglandin derivatives more bleeding at their first menses after operation, and gauze
Some scholars suggested that the administration packing is needed to fill the vagina for hemostasis, which is
of misoprostol (prostaglandin E1 analog) orally or a more common situation. There were two cases with severe
rectally could strengthen the uterine contractility and late postoperative bleeding that occurred in the Hysteroscopy
reduce postoperative bleeding. Center of Fuxing Hospital, Capital Medical University, and
3. Hysteroscopic examination and coagulation for both characteristics and managements are seen in Table 12.16.
hemostasis The hemorrhage was related to the application of sodium
During the period from 48 to 72 h to 1 week after hys- hyaluronate in the first case and was related to adenomyosis
teroscopic surgery, the patient occasionally encounters a in the second case.
Table 12.15 Characteristics and managements of postoperative bleeding in four cases with hysteroscopic surgeries
Details in operations and
No. postoperations Blood loss (mL) Clinical manifestations Managements
1 TCRS with heavy bleeding 800 Hemorrhagic shock Bleeding stopped after balloon
observed within 8 h after operation tamponade for 8 h and blood
transfusion of 600 mL
2 TCRM for inward-protruding 300 (–) Bleeding stopped after balloon
intramural myoma, with heavy tamponade for 8 h and blood
bleeding observed within 6 h after transfusion of 200 mL
operation
3 TCRE for menorrhagia after heart 1000 Hemorrhagic shock and Bleeding stopped after
valve replacement and anemia hysteroscopic coagulation
discontinuation of warfarin.
Continuous bleeding could not be
stopped within 24 h after operation
4 TCRM for a 5 cm myoma in 600 Hemorrhagic shock Bleeding stopped after blood
posterior wall of the cervical canal. transfusion and compression
An outburst excessive bleeding with tamponade
occurred from the base of the
myoma on the fourth day after
operation
Table 12.16 Characteristics and managements of bleeding in the late surface of the uterine cavity postoperation. A thorough curet-
postoperative period in two cases with hysteroscopic surgeries tage may achieve a complete healing. Colgan et al. carried out
Blood a study on the healing process of endometrium after hystero-
Details in operations loss Clinical scopic endometrial ablation with rollerball. Findings from
No. and postoperations (mL) manifestations Managements uterine specimen within 3 months after operations included
1 Intrauterine 1000 Hemorrhagic Blood acute inflammation, myometrial necrosis, florid foreign bod-
injection of 3 mL shock and transfusion,
sodium hyaluronate anemia laparotomy, and
ies, and granulomatous reactions. After 3 months postopera-
following TCRM subtotal tion, persistent granulomatous foreign body reaction and
for preventing hysterectomy, obvious endometrial scarring might be detected from the spec-
intrauterine with foreign imen of the uterus. They concluded that postoperative patho-
adhesions. An body giant cells
outburst of in the base of
logical reaction of hysteroscopic endometrial ablation should
excessive bleeding myoma revealed be recognized as granulomatous endometritis. There has been
occurred on the by histological a patient with postoperative granulomatous endometritis cured
11th day with examination by uterine curettage in the Hysteroscopy Center of Fuxing
conservative
treatment being
Hospital, Capital Medical University.
ineffective
2 TCRE for DUB 700 Hemorrhagic Blood
with adenomyosis shock and transfusion and 12.4 Infection
diagnosed anemia subtotal
intraoperatively. hysterectomy.
Five months later, Severe Yuhuan Liu
repeated heavy adenomyosis
hemorrhage was identified, The morbidity of infection after hysteroscopic examination
occurred after which reached or surgery is very low, just between 0.01 and 2% as reported
carrying a heavy the serosa in
load, with right cornua in the literature. Postoperative infection is associated with
conservative many factors, such as disinfection of operating instruments,
treatment being and whether or not the patients have reproductive infectious
ineffective disease, body resistance, or application of antibiotic prophy-
laxis, etc.
12.3.5 Prolonged Bleeding

in the Postoperative Period 12.4.1 Characteristics of Female Genital
Organs
Very few patients may have prolonged postoperative bleeding,
which may be related to inflammatory reactions, poor heal- The female genital organs are divided into internal genital
ings, and granulomatous foreign body reactions in the cutting organs and external genital organs. The internal genital organs
386 E. Xia et al.
communicate with the outside by way of the vagina. The nor- cant increase in positive rate of virulent Escherichia coli and
mal vaginal discharge is weakly acidic, which can prevent Bacteroides fragilis. Lactic acid is produced by metabolism
bacteria from reproduction in the vagina; the glands in the of lactobacillus and sustains the vaginal pH of 3.8–4.2,
mucosal layer of cervical canal can secrete a small amount of which is advantageous to the growth of vaginal endosymbi-
alkaline mucus, forming cervical mucus plug, which has a onts but disadvantageous to the growth of bacteria causing
defensive function. Under normal circumstances, there are a bacterial vaginosis, thus maintaining the vaginal health.
variety of microorganisms in the female vagina, belonging to Surgical wound not only provides an access for bacteria to
the endogenous microorganisms; the bacteria community is invade into the body, but also promotes the priority growth
made up of Gram-positive or Gram-negative aerobes and and reproduction of virulent potential pathogens in the
anaerobes. The common aerobic bacteria include lactic acid vagina so as to create favorable conditions for postoperative
bacillus, corynebacterium, non-hemolytic streptococcus, infection. If postoperative vaginal bleeding or fluid flow sus-
staphylococcus epidermidis, enterococci and Escherichia tains in the vagina, the normal vaginal internal environment
coli, vaginal Gardiner’s bacteria, etc. Anaerobic bacteria is disrupted; at the same time the blood is a good bacterial
include peptococcus, peptostreptococcus, bacteroides fragi- culture medium and is conducive to bacterial growth, result-
lis, fusobacterium, and candida as well. The vagina is estab- ing in pelvic infection.
lished in a state of equilibrium with the microflora. When the
ecological balance is destroyed by low levels of body immu- 12.4.2.3 Factors Related to Instrument
nity, changes in endocrine level, and some external factors Since hysteroscopic instruments have fine structure, more
(such as tissue damage), the resident flora may become patho- valves, and narrow channels, which bring difficulties in
genic bacteria, causing infection. Therefore, endogenous cleaning, particles and protein materials remaining in the
microorganisms in the female lower genital tract are often apparatus provide shelter for potentially pathogenic bacteria,
pathogenic bacteria of the reproductive tract infection. and are not easy for disinfectants to infiltrate. Meanwhile,
the external cables for hysteroscopy cannot be disinfected
with high-pressure steam. The surgical instruments of hys-
12.4.2 Factors Causing Postoperative Infection teroscope are directly in contact with genital organs, if steril-
ization is not achieved, it is extremely easy to cause infection
12.4.2.1 Factors Related to Procedures when examination, resection, lysis, and other procedures are
During hysteroscopic surgery, the cervical canal is dilated to performed.
10 mm in diameter, which may cause some fibers in cervix to
fracture, resulting in an open cervical orifice to communicate
the uterine cavity with the outside world. At the same time of 12.4.3 Microbiological Characteristics
the operative procedure, repeat movements and insertion of of Infections After Hysteroscopy
hysteroscope can bring bacteria flora in the vagina and uter-
ine cervix into the uterine cavity. Application of uterine dis- The infections after hysteroscopy are mostly endogenous
tention medium may carry pathogens into the pelvic cavity infection caused by the parasitic potentially pathogenic bac-
through the fallopian tubes, or into local or blood system teria in the vagina. Generally, it is a mixed multiple bacterial
through the denuded injured endometrial or muscle tissues, infection, and different bacteria have synergistic effects. For
which causes pelvic infection. Boubli et al. reported that in example, after aerobic bacteria invade the cutting surface and
women with normal vaginal sample tests, 25% were found to oxygen is consumed, a hypoxia environment is produced,
have infections with pathogenic bacteria in uterine cavity at which is helpful for the anaerobic bacteria to multiply rap-
the end of hysteroscopic surgery. While in women with vagi- idly and continue to destroy the deep tissues. The main
nal sample contaminated, 50% were found to have bacterial pathogenic bacteria include aerobes such as Escherichia coli
infections in uterine cavity. The relative risk of intrauterine and streptococcus and anaerobes such as peptostreptococ-
bacterial contamination during hysteroscopic operation in cus, peptococcus, and bacteroides fragilis. Anaerobic bacte-
women who have vaginal contamination was 8.75. ria are often pathogenic bacteria of deep pelvic infection.
12.4.2.2 Changes in the Internal Environment

of Reproductive Tract 12.4.4 Diagnosis and Treatment
The interference of diagnostic or operative hysteroscopy of Postoperative Infection
may cause obvious change and transformation of vaginal
microflora. There are not only more bacteria flora species Infection following hysteroscopic operation is commonly
isolated from the vagina than that prior to surgery, but a mild pelvic inflammation, which is always endometritis or
decrease in positive rate of lactic acid bacillus and a signifi- myometritis.
12.4.4.1 Clinical Symptoms two cases (0.79%) and the etiological agent was Chlamydia
Postoperative temperature may exceed 37.5 °C and continue trachomatis. Maher and Hill reported in 100 cases undergo-
without any decline. The patients can experience persistent ing TCRE for AUB, two cases (2%) developed secondary
or paroxysmal abdominal dull pain or sharp pain, and perito- infection without any detection of pathogenic bacteria. Vilos
neal irritation sign may be detected in severe cases. Vaginal et al. reported on 800 women who underwent endometrial
discharge may be increased, being bloody or purulent, and ablation, four cases developed endomyometritis (0.5%).
mostly with odorous smells like stinking fish. Cravello et al. reported on 195 TCRP for hemorrhagic endo-
metrial polyps, with only one case of infection occurred.
12.4.4.2 Physical Signs Propst et al. reported on 925 women who had hysterosco-
Since postoperative infection is often endometritis or myo- pies, with two cases developing myometritis during TCRM
metritis, cervical motion tenderness and uterine tenderness and the incident rate of infection 0.22. Hysteroscopy postop-
may be detected by vaginal bimanual examination. If there erative infection is generally mild pelvic inflammatory dis-
are pelvic peritonitis and/or pelvic empyema, tenderness, ease, but serious infections also occur occasionally. Mears
rebound tenderness and muscular tension at lower abdomen and Fox reported two cases of infection occurring after diag-
can be obviously detected. nostic hysteroscopy for irregular uterine bleeding. One case
developed pelvic abscess with septicemia 6 days after diag-
12.4.4.3 Auxiliary Examination nostic hysteroscopy, who recovered after 6 weeks of anti-
Blood routine examination can reveal an increase of white infection treatment. Another case developed right
cells, with a significant rise of neutrophil granulocyte. Pelvic tubo-ovarian abscess 2 weeks after hysteroscopic examina-
ultrasonography can help to discover pelvic empyema, and tion, who underwent abdominal excision via laparotomy.
CT or MRI can be applied if necessary. Blood culture and Two cases were confirmed to have a history of chronic sal-
drug sensitivity test should be conducted if bacteremia or pingitis and were not administered prophylactic antibiotic
septicemia is suspected. therapy after diagnostic hysteroscopy. Amin-Hanjani and
Good reported that a 47-year-old woman developed pyome-
12.4.4.4 Treatment tra and bacteremia following endometrial resection and abla-
Since the main pathogenic bacteria of infection following tion for menorrhagia without administration of prophylactic
hysteroscopic operation includes aerobe and anaerobe, with antibiotics. Uterine cervical discharge and blood culture
anaerobe often being the main pathogenic bacteria of pelvic revealed colon bacillus. The patient was cured by placement
deep infection, broad-spectrum antibiotics, especially those of an intrauterine drain and intravenous antibiotic therapy.
being very effective in killing the anaerobe, should be Parkin reported on a 40-year-old woman who had menor-
applied. Pelvic infection caused by chlamydia, mycoplasma, rhagia and anemia due to a small myoma in posterior uterine
and fungus also deserves attention. Mild pelvic infection can wall, On the second day after TCRE, she experienced diar-
be cured by oral antibiotics, whereas severe pelvic infection rhea and shock. Transabdominal exploration found no bowel
should be treated by intravenous antibiotics. For cases of pel- injury, while blood cultures and peritoneal fluid cultures dis-
vic abscess, surgical treatment should be considered when covered Staphylococcus aureus. This patient resulted in
medication is ineffective. death on the eighth postoperative day due to multiple system
failure and invalid rescue. Li et al. reported that a 42-year-old
woman who had renal failure and required renal dialysis had
12.4.5 Reports of Infections After Operative a hysteroscopy for DUB. She experienced abdominal pain
Hysteroscopy after operation. Candida albicans were discovered from the
cultures of both a higher vaginal swab and the peritoneal
The literature report on the incidence of infections after dialysate effluent, which confirmed the diagnosis of fungus
operative hysteroscopy varied. Aydeniz et al. reported among peritonitis. They thought it was due to the distension medium
21,676 hysteroscopic procedures in 92 German Hysteroscopy carrying the fungus into the peritoneum. McCausland et al.
Centers, three cases developed endometritis, and its inci- reported three cases of developed ovarian abscess after oper-
dence rate of infection was 0.01%. Perez-Medina et al. ative hysteroscopy, all of whom had a past history of pelvic
reported in 6123 office diagnostic hysteroscopies, three inflammatory disease and were not given prophylactic anti-
cases (0.05) developed pelvic inflammatory disease. The biotics. Two of three underwent TCRP and one case had
blood culture was negative and the vaginal discharge culture TCRM. Rullo et al. reported that one uterine perforation
revealed non-specific bacterial flora. Bracco et al. reported occurred in one case during operative hysteroscopy and an
among 253 women undergoing diagnostic hysteroscopy, abscess of the left parametrium and round ligament occurred
germs were identified preoperatively in the cervical canal in after operation. Jeanette et al. reported a case of a woman
35 cases, of which pelvic inflammatory disease developed in who underwent a rollerball endometrial ablation. After the
388 E. Xia et al.
procedure, she developed pelvic abscess and a Bartholin’s 55–60 °C and a relative humidity between 60 and 80% is
abscess on the fourth day and hepatic abscess on the eighth kept for 6 h in ethylene oxide sterilizer. The advantage
day. Philips reported on one case who underwent diagnostic includes relatively less damage, and disadvantage is a longer
hysteroscopy due to menorrhagia and experienced peritonitis disinfection time. (4) Immersion in chemical disinfectants:
following the procedure. Laparoscopy revealed a normal When 2% alkaline glutaraldehyde is used for sterilization,
uterus, and peritoneal exudates examination discovered the instruments must be immersed for 10 h. Since it has cor-
white blood cells without microorganisms. The patient was rosivity to instruments and irritation to skin, mucosa, and
cured by administration of peritoneal lavage and antibiotics. respiratory tract, the instruments should be rinsed in sterile
Yap et al. reported that a 41-year-old woman who suffered water after being taken out from the disinfectants.
from late lupus nephritis and received renal dialysis under-
went TCRE due to menorrhagia. Peritonitis was diagnosed 12.4.6.2 Strict Sterile Operation
one day after operation because of the turbid peritoneal fluid, Dhaliwal et al. counted 4032 cases who underwent obstetric
and intravenous and intraperitoneal injection of antibiotics and gynecological operations and found that the postopera-
were applied. The patient then developed septicemic shock tive infection rate was 2.2% and was 0.9% in gynecological
and was cured after intensive care and selecting proper anti- surgery, with the common pathogens involving Enterococcus,
biotics. Lin et al. reported one case of tubo-ovarian abscess Staphylococcus, and Klebsiella species. So they held that the
and septic shock which developed following hysteroscopic main source of postoperative infection was vaginal flora,
diagnosis for endometrioma. Golan et al. reported that one which could be minimized by local sterilization. The vagina
case developed sepsis followed by DIC after hysteroscopic is the only way for hysteroscopic operation, so strict disin-
removal of conceptive remnants and was cured by fection is more important especially in the consecutive hys-
resuscitation. teroscopic examination or surgeries, and the operators must
operate under sterile conditions. Five percent iodophor disin-
fectant is a broad-spectrum bactericide and can kill the strep-
12.4.6 Preventive Measures Against Infection tococcus, intestinal bacteria, and pathogenic yeast. It has no
irritation to skin and mucosa and is applicable to disinfection
Most infections are preventable. Even if the infection is inev- of vulva and vagina, so it has been a routine disinfectant used
itable, we can take preventive measures to reduce the degree before hysteroscopic diagnosis and surgeries.
of infection and should try best to eliminate the various fac-
tors inducing infection and enhance the patient’s own 12.4.6.3 Improvement in Patient Status
resistance. Patients with the conditions like genital inflammation, mal-
nutrition, anemia and diabetes, or aged women with weak
12.4.6.1 Strict Sterilization of Instruments resistance are all underlying factors leading to infections,
The surgical instruments of hysteroscope come into direct who should be promptly identified and treated prior to
contact with genital tract. During examination and surgery, if operation.
sterilization is not qualified, it is extremely easy to cause
infection, so the sterilization of hysteroscopic diagnostic and 12.4.6.4 Application of Prophylactic Antibiotics
operative instruments is required to achieve killing germs. In recent years, with the development of antibiotics, great
The methods for disinfection of instruments include: (1) changes have taken place in the concept of preventive use of
High-pressure steam sterilization: It keeps a temperature at antibiotics during the operative period compared with the
121 °C for 20–30 min and is the most thorough disinfection traditional concept. Research findings showed that the peri-
method, which is applicable to metal appliances. After operative prophylaxis can reduce the occurrence of infec-
repeated high-pressure sterilization, the joints of some tious complications after operation. Bhattacharya et al.
devices can be inflexible. (2) Low temperature sterilizers: studied the incidence of bacteremia following hysteroscopic
The liquid used in sterilizers is sterile water and bactericidal surgery and found that it was 16% in the non-antibiotic
agent which has been processed by sterilizers. It works at a group, while 2% in the group who received intravenous anti-
low temperature between 45 and 55 °C for 30–40 min, after biotics at induction of anesthesia, with significant differ-
which the instruments should be rinsed by sterile water ences between them. Marchino et al. also held that even short
repeatedly so as to ensure their asepsis and cleanliness with- limited operations could interfere the patient’s immune sys-
out any residual of chemical materials. Then the water is tem which led to lowering of her resistance. As a result, the
blown dry automatically. Since it has little damage to instru- changes in microbial flora encouraged the growth of bacte-
ments, it has become a commonly used method for steriliza- ria, so the application of antibiotic prophylaxis was very
tion of hysteroscopic instruments. (3) Ethylene oxide important. Selection of antibiotics should meet the following
sterilization: 800 mg/L ethylene oxide at a temperature of criteria: broad antibacterial spectrum; high bactericidal
power; high permeability of the tissues; capacity to maintain nor underlying susceptible factors, prophylactic antibiotics
effective concentration in tissues for longer time, single drug will not be used for hysteroscopic diagnosis, and for women
use which can achieve the purpose of prevention; less resis- who undergo a shorter and simple hysteroscopic surgery
tant strains; few side effects; proper cost–benefit ratio. The (e.g. TCRP), prophylactic antibiotics will not be used, and
timing of antibiotic administration is very important. If the postoperative infections seldom develop.
effective concentration of the drug can be reached before In conclusion, hysteroscopic examination or surgery has a
contamination, it may produce the maximum effect. Although certain degree of risk of infection. As long as we have suffi-
most operation is done in sterile conditions in theory, the cient understanding and effective prevention, infection, espe-
highest risk period of the bacterial contamination is still in cially severe infection will rarely occur or not occur, which
operation process. The reasonable time for antibiotic pro- will be more conducive to the implementation of operative
phylaxis should be before possible contamination occurs, so hysteroscopy and beneficial to thousands of women suffer-
that adequate drug concentrations in the relevant tissues can ing from uterine diseases.
be reached in patients in order to prevent subsequent bacte-
rial growth and reproduction. Generally, the use of prophy-
lactic antibiotics should be prescribed once before and after 12.5 Venous Air Embolism
operation, respectively. If the operative time is too long, an
additional medication can be given during operation to main- Enlan Xia
tain adequate concentrations in tissues. However, the
research findings made by Hayashi et al. showed that the Venous air embolism (VAE) or venous gas embolism (VGE)
administration of intravenous cefotiam dihydrochloride is caused by the entry of air into the venous system, which
(CTM) on the induction of anesthesia was similar in preven- can be a consequence of trauma, iatrogenic complication
tive effect to oral cefpodoxime proxetil (CPDX- PR) given (especially central venous intubation or pressurized intrave-
for 3 days after operation, and there was no significant differ- nous infusion), or can also occur in some surgical proce-
ence. It was believed that the administration of oral antibiot- dures, being a serious, rare but fatal complication. There are
ics appeared to be a safe, convenient, and relatively cheap three main types of gas: oxygen, CO2, and nitrogen. Air
postoperative prophylaxis. emboli are bubbles of nitrogen gas. VAE can lead to right
Generally, the pathogens causing pelvic inflammatory ventricular dysfunction and pulmonary injury, which has
disease are streptococcus, staphylococcus, Escherichia coli, been reported in the research field of neurosurgery, urology,
and other anaerobes. However, due to specificity of the hys- and cesarean section. The earliest VAE was documented in
teroscopic pathway, pelvic inflammatory disease caused by 1830, which was extremely rare a 100 years ago. With the
chlamydia, mycoplasma, and fungus is also worthy of atten- rapid development of medical technology and diving under
tion. For patients with pelvic inflammatory disease, the high pressure, especially as the Navy submarine escape
application of prophylactic antibiotics is especially impor- training becomes more frequent and cardiovascular surgical
tant. McCausland et al. reported that in group one, four (2%) operation increases in quantity and difficulty, VAE is no lon-
of 200 cases without using prophylactic antibiotics had a ger a rare disease. By estimate, there are more than twenty
past history of pelvic inflammatory disease, three of four thousand people around the world each year suffering per-
cases developed ovarian abscess after operative hysteros- manent sequelae of VAE without timely and correct treat-
copy; in group two, 10 (2%) of 500 cases who were given ment. Some patients suffering from VAE even die in a short
prophylactic antibiotics had a past history of pelvic inflam- time. Gottlieb et al. reported that if untreated, the patients
matory disease, no infection occurred after operative with VAE had a mortality of as high as 93%. Therefore, it is
hysteroscopy. essential to administer the timely and correct treatment to
In recent years, whether hysteroscopic diagnosis and patients. In recent years, along with the universal application
operation must apply prophylactic antibiotics is still a con- of operative hysteroscopy, there are reports on air embolism
troversy. Isaacson held that the application of prophylactic induced by hysteroscopic procedures, including diagnostic
antibiotics was not necessary after hysteroscopic examina- CO2 hysteroscopy and transcervical resection (TCR) of uter-
tions. Thinkhamrop et al. reviewed six literatures to evaluate ine lesions. In a review of literature in recent 10 years, its
the effectiveness of antibiotics in preventing infections after morbidity is shown in Table 12.17.
hysteroscopic examination and did not make the conclusion
that prophylactic antibiotics could prevent intrauterine infec-
tions posthysteroscopic procedures. In the Hysteroscopy 12.5.1 Incidence
Center of Fuxing Hospital, Capital Medical University, we
strictly confine the administration of prophylactic antibiot- The exact incidence is uncertain, but subclinical gas emboli
ics. For women who have neither a history of pelvic infection in hospitals may be very common. VAE clinically diagnosed
390 E. Xia et al.
Table 12.17 VAE induced by operative hysteroscopy

Author Year Procedures Cases of VAE Notes
Pierre et al. 1995 CO2DHS 3 Treatment with HBO and death in
one case
Brooks 1997 Operative hysteroscopy 13 Death in nine cases (worldwide)
Brandner et al. 1999 CO2 DHS 1 0.51% undiscovered
Fukuda et al. 2000 TCRM 1 The surgery suspended and the
patient resuscitated
Xia Enlan 2001 5% glucose DHS 1 The patient resuscitated
Adducci and De Cosma 2001 Operative hysteroscopy 1 The patient resuscitated
Imasogie et al. 2002 Operative hysteroscopy 1 Gas caused by electroresection and
the patient resuscitated
Corson 2002 Operative hysteroscopy 1 The patient resuscitated
Grove et al. 2005 Operative hysteroscopy 1 The patient resuscitated
Brugmann et al. 2007 Operative hysteroscopy 2 Discovered by anesthetist and the
patient resuscitated
Note: HBO hyperbaric oxygen, DHS diagnostic hysteroscopy
following placement of central venous (CV) catheter is <2%. 12.5.2 Etiology

Research findings made by Brandner et al. showed that unde-
tected emboli were present in 0.51% of patients. In recent The gas causing VAE may come from CO2 in distending
years, along with the universal application of operative hys- uterus, air in the inflow pipe, and bubbles generated in tissue
teroscopy, there are reports on venous air embolism induced vaporization, which may happen at the beginning or during
by hysteroscopic surgeries, including diagnostic CO2 hyster- the procedure. The gas enters the blood circulation through
oscopy and transcervical resection (TCR) of uterine lesions. the opened veins in the cutting surface, and the increased
In 1995, Pierre et al. reported among 5140 CO2 hysterosco- intrauterine pressure is the promoting factor. The gas enters
pies, air embolism occurred in three cases, with its incidence the right ventricle along with blood flow, and the cardiac
rate 0.058%. In 1999, Brandner et al. reported 3932 CO2 hys- impulse prompts the gas and intracardiac blood to mix, form-
teroscopies. Air embolism occurred in one case, with its inci- ing large volumes of bubbles. The cellulose, separated from
dence rate 0.03%. In 1997, Brooks reviewed the related “mixing,” infiltrates into the pulmonary artery end, which
literature around the world and found that 13 cases had VAE makes the conditions more complex. The blood in pulmo-
in the course of hysteroscopic procedure. Some air embo- nary arteriole is replaced by bubbles, thus gas exchange is
lisms were asymptomatic, not diagnosed, or not reported, so reduced. Intrapulmonary arteriovenous anastomoses are
its exact incidence is difficult to estimate. Imasogic et al. open in great number, arteriovenous short circuits aggravate
reported that the incidence of VAE during operative hyster- hypoxia. Bubbles block the pathway of pulmonary artery
oscopy was 10–50%, and catastrophic outcomes occurred blood flow, which leads to a rise in the pulmonary arterial
scarcely at a rate of three in 17,000 procedures. pressure and a drop in end-tidal CO2 pressure. Because the
Bloomstone et al. carried out a study to evaluate the fre- right ventricular pressure is higher than the left ventricular
quency of gas formation with 11 cases undergoing hystero- pressure, eventually circulatory failure results and sudden
scopic monopolar resection and three cases in control group. cardiac arrest occurs. The foramen ovale previously closed
The formation of gases in the inferior vena cava, hepatic veins, reopens in some adult patients, thus causing emboli to the
and right heart was detected by echocardiography and serum brain and other organs.
tests. As a result, gas bubbles formed in hepatic veins and right The immediate causes of death are brain hypoxia, failure
heart were identified in ten cases of surgery group, while no caused by right ventricular dilatation; or left ventricular fail-
gas was discovered in control group. There were no changes in ure secondary to myocardial ischemia caused by hypoxia
coagulation function among cases in both groups. They and decreased cardiac output. After gas embolism occurs,
insisted that gas bubbles could be discovered in most cases by pulmonary hypertension, arteriovenous shunt, and increased
echocardiography during hysteroscopic resection. Whether vascular permeability caused by hypoxia result in pulmonary
the patients had clinical presentations or not is correlative with edema and respiratory distress syndrome. If volume is
anatomic characteristics and the volume of bubbles. greater than 300 mL, death follows.
12.5.3 Pathogenesis regarded as an index of diagnosis of pulmonary gas embo-

lism. The experimental findings made by Drummond showed
In neurosurgical operations, the occurrence rate of air embo- that there was a close relationship between the change in
lism is 25–50%. The reasons are: when neurosurgery is per- CO2 concentration and the amount of bubbles into the vein.
formed, in order to expose the head injury, the patient is
placed in a sitting position. Since the heart level is below the
brain, when the heart dilates each time, negative pressure is 12.5.4 Pathophysiology
generated in the vein, which can lead to air inhalation through
the opened skull and dural venous sinus. Once the air enters When the air into the venous system affects the right ventri-
the venous circulation, the bubbles in the right ventricle cle, pulmonary circulation, and systemic circulation (if there
block the blood flow, causing a rise in the pulmonary arterial is a right-left shunt), symptoms and signs may develop.
pressure. In the early development of gas embolism, the end- When embolism occurs in the vein, the blood vessels become
tidal CO2 pressure drops, and finally, circulation failure and wider and wider, and the small bubbles or a small amount of
sudden cardiac arrest occur. Because there is a higher degree gas produces no effect on the circulation prior to its entry
of the increased right ventricular pressure than that of the left into the heart and arteries without development of symp-
ventricular pressure, 15% of the foramen ovale previously toms. A large amount of gas (3–5 mL/kg body weight) can
closed in adult patients reopen, thus causing emboli to the trap right ventricular ejection, leading to cardiogenic shock
brain and other organs. There is the same mechanism in and cease of circulation. A moderate amount of gas accumu-
gynecologic surgeries, but the sitting position is shifted to lates in the pulmonary circulation and causes injury to the
head-down tilt, with the level of heart lower than the level of lungs, the pulmonary capillary constriction, pulmonary
uterus, resulting in a decrease in venous pressure, and there hypertension, vascular endothelial damage, and permeability
is significant pressure difference between the central circula- pulmonary edema may develop. When an emboli enters the
tion and the uterine cavity. Pressure difference comes from artery, because the vessels become thinner and thinner, it
the intravascular negative pressure, and also the extravascu- finally blocks the small arteries with regional blood flow
lar positive pressure, or both, which may be seen in trauma occluded, leading to serious consequences. But its outcome
or when positive and negative pressure interchanged. If the depends on the location of the arterial embolism, if it occurs
head of the bed is tilted down too much and the height differ- in the brain, permanent brain damage can be caused.
ence between the uterus and the heart is ≥26 cm, the pressure The brain is one of the organs in the body which requires
difference between the uterine cavity and systemic circula- the greatest amount of oxygen. The brain weight accounts
tion may prompt the air to be inhaled into the blood circula- for only 2–3% of human body, but brain oxygen consump-
tion and accelerate the quantity and speed of air inhalation. If tion accounts for 20–30% of the total oxygen consumption,
the large venous sinus in the deep uterine muscle wall is and 15% of cardiac output goes to the brain, and there is
open and communicates with the outside, the outside air can almost none of energy reserve in the brain tissue. If cerebral
be absorbed into the venous circulation. When the uterine blood supply and oxygen supply completely discontinue, the
distension media is infused into the uterus under pressure, patient will lose consciousness in 8–15 s, and irreversible
this process can be aggravated. When the intrauterine pres- damage will occur in 6–10 min.
sure exceeds venous pressure, asymptomatic, symptomatic In 2008, some new ideas about original reason and sud-
and fatal VAE may occur. den death of gas embolism were put forward in two litera-
Pulmonary gas embolism can cause lung tissues to release tures. Chang et al. reported on death in one patient who
some substances (such as smooth muscle active substance, developed VAE which resulted from ureteroscopic litho-
5-serotonin, histamine, bradykinin, prostaglandins, etc.), tripsy by Ho:YAG. When the procedure was coming to an
which may cause the bronchial smooth muscles and pulmo- end, the patient complained tightness over her chest and
nary vessels to constrict and lead to an increase in pulmonary promptly developed into unconsciousness, followed by cir-
capillary permeability, thus resulting in an increase in pul- culatory failure and cardiac arrest. The procedure was
monary resistance, pulmonary artery pressure, and plasma stopped immediately, and mask 100% oxygen inhalation,
exudation, leading to pulmonary edema and difficulty in endotracheal intubation, establishing the vein passage, and
breathing. The pathogenesis of pulmonary endothelial injury cardiopulmonary resuscitation were conducted. Internal jug-
may be the release of platelet-fibrin cytolymph from right ular vein was catheterized. The crepitus was detected when
heart and the activation of neutrophil, platelet, and microvas- performing external chest compression, and 20–30 mL
cular gas–blood interface, and lipid peroxide and oxygen frothy blood was sucked out from the catheter, which indi-
ion-mediated injury. When pulmonary air embolism occurs, cated VAE. Transesophageal echocardiography revealed a
alveolar dead space expands and the end-tidal CO2 drops. At large volume of gas emboli in right heart atrium and right
present, the determination of CO2 content has been clinically heart ventricle. The heart contraction could not be restored
392 E. Xia et al.
after conduction of adrenalin and cardiac massage. The cases of VAE, three patients lost their life with the fatality
patient died 40 min later for failure in resuscitation. All rea-rate 27.3%, and one patient was left with permanent brain
sons including entry of the air into the bladder by insertion damage. The morbidity of gas embolism induced by opera-
and withdraw of the scope, and entry of the air via gap tive hysteroscopy reported in literatures is seen in Table 12.19.
because of empty of the irrigating fluid, broken inflow pipe, Among 15 cases of VAE collected, 9 patients died with the
loose connection to the sheath or replacement of inflow pipe mortality rate of 60%, and one case was left with permanent
were all excluded. The only possible reason might be the gas neurological damage. It can be seen from two tables that the
caused by tissue vaporization entering right heart ventricle. fatality rate of VAE caused by operative hysteroscopy is
The entering of gas when VAE occurs is insidiously and the higher than that of diagnostic CO2 hysteroscopy, and there is
patient may have no characteristic symptoms; therefore, the no difference between various types of surgery.
real source of gas is uncertain. One case of VAE had occurred during diagnostic hyster-
Rademaker et al. first reported on one case of paradoxical oscopy in combination with ultrasonography in the
gas embolism which occurred during hysteroscopic surgery Hysteroscopy Center of Fuxing Hospital, Capital Medical
and was detected by transesophageal echocardiography. University. This 42-year-old woman who initially being
During TCRE with bipolar electrode, at 20 min after begin- healthy and having normal menses suffered from persistent
ning of the procedure, end-tidal carbon dioxide ( ETCO2 ) was vaginal bleeding for 2 months. No tissues were discharged
decreased to 2.4 kPa (1 kPa=7.5 mmHg); arterial oxygen with the blood. She had four pregnancies and two live births,
saturation ( Sa O2 ) was decreased below 90%, with the lowest with her last delivery 11 years ago. During operation, the
to 40%; and a loud mill-wheel murmur was detected by pre- patient was placed in lithotomy position, ultrasonography
cordial auscultation. VAE was diagnosed and the procedure scan was firstly conducted and revealed that the uterus was in
was stopped immediately. The patient was put in a horizontal position, enlarged by 70 mm × 66 mm × 56 mm,
Trendelenburg position and was ventilated with continuous and there was an echo-free zone of 20 mm × 10 mm, which
pure oxygen. No gas was retrieved through a central venous was suspected to be fetal sac. No abnormalities were found
catheter which was inserted in the internal jugular vein. At in bilateral adnexa. An HYF-XP fiber hysteroscopy (outer
15 min after partial pressure of CO2 ( Pa CO2 ) beginning to diameter of the tip 3.1 mm) was inserted with the application
fall, a 7.4 MHz transesophageal echocardiography (TOE) of automatic distention pump, 5% glucose as distending
probe was inserted and no gas in right atrium and right ven- medium, the distension pressure set at 120 mmHg, and uter-
tricle was discovered. However, echo-dense materials were ine fluid velocity at 240 mL/min. The length of uterine cavity
identified in left atrium and left ventricle, which indicated was 10 cm. Under hysteroscope, the cavity first appeared
paradoxical emboli. The paradoxical emboli described in bloody and obscure, and then bubbles were seen tumbling in
this report might be caused by gas emboli entering left heart the uterine cavity. When checking the distending system, no
from right heart through atrial septal defect, open foramen fluid was left in the container. The distention fluid was added
ovale, pulmonary arteriovenous malformations or arteriove- immediately, and the procedure continued. Four minutes
nous fistula. So cardiovascular and neurological complica- later, the patient suddenly felt suffocated and coughed with-
tions can be promptly developed when VAE occurs, which out end, accompanied with a cyanosed face. Her blood pres-
even threatens the patients’ life. sure was 60/40 mmHg and heart rate 40 beats/min. She was
immediately given mask with positive pressure oxygen inha-
lation. The veins were kept open and dexamethasone 20 mg
12.5.5 Clinical Manifestations was injected intravenously, the patient was sweating pro-
fusely and felt peripheral coldness, but kept consciousness.
Clinical manifestations of VAE are related to the volume of Lung auscultation revealed low breath sounds with no rales.
embolized gas. All the early emergent symptoms are usually Seven to 8 min later, her symptoms were relieved, and gen-
found by anesthesiologists, such as a sudden drop in the end- eral conditions were improved with the blood pressure at
tidal CO2 pressure, slow heartbeat and a decrease in blood 90/50 mmHg. Sixteen minutes later, her heart rate was 78
oxygen saturation, and auscultation of the precordium beats /min, and ECG showed no abnormalities. Then urine
revealing water-wheel murmur, clicking and gurgling sound, HCG test was taken and the result was positive. The next day,
which is a typical sign of air into the heart. When more air artificial abortion vacuum aspiration was performed
enters, there is an increased resistance to blood flow, leading smoothly with her blood pressure at 100/70 mmHg. This
to hypoxia, cyanosis, decreased cardiac output, hypotension, patient was found to have uterine bleeding for more than 2
and tachypnea. Cardiopulmonary failure develops rapidly months due to the early threatened abortion, so the uterus
and death follows due to sudden cardiac arrest. The morbid- had rich blood supply and broken intrauterine mucosa. In
ity of gas embolism induced by diagnostic CO2 hysteroscopy addition, the empty container permitted the air to enter the
reported in literatures is described in Table 12.18. Among 11 cavity via the irrigating pipe, and intraoperative distension
Table 12.18 Characteristics and outcomes of air embolism during diagnostic hysteroscopy
Authors Year Distention media Clinical manifestations Outcomes
Nishiyama and 1999 CO2 Convulsion and confusion occurred at the removal of the Died 16 h later
Hanaoka hysteroscope; the pulse impalpable. Treated by cardiac
massage, trachea intubation, and medication
Sherlock et al. 1998 CO2 Recovered
Sudden and rapid falls in ETCO2 and Sa O2 on monitor;
pulseless and cyanosed. Treated by oxygen inhalation and
hyperbaric oxygenation
Behnia et al. 1997 CO2 A noncardiogenic pulmonary edema developed in the recovery Recovered
room
Ghimouz et al. 1996 CO2 Ventricular tachycardia occurred after 2 min of CO2 Transient blindness for
insufflation under general anesthesia, followed by a circulatory 3 min
arrest. Improvement achieved by 2 min of cardiopulmonary
resuscitation
Corson et al. 1996 CO2 Bradycardia occurred suddenly after diagnostic hysteroscopy Left with permanent brain
for 9 min. Transesophageal ultrasonography revealed air in injury
four heart chambers with open oval foramen
Vo Van et al. 1992 saline A respiratory distress occurred at the end of the procedure, Died
followed by cardiac arrest. Treated by cardio-respiratory
resuscitation
Crozier et al. 1991 CO2 Three cases developed circulatory collapse and cardiac arrest Recovery
5–8 min after the start of examination. A mill-wheel murmur
detected by auscultation following resuscitation and
disappeared 5 min later
Obenhaus and 1990 CO2 Bradyarrhythmia, drop of blood pressure, metallic heart sound, Recovery
Maurer and hypercapnia
Gomar et al. 1985 CO2 Cardiovascular collapse, cardiac arrest, and a mill-wheel Irreversible brain damage
murmur and died a week later
pressure was at 120 mmHg. Under such high pressure, the hypoxemia and hypocapnia. There are no other abnormal
air in the irrigating pipe passed through the uterine venous laboratory results.
sinus into the right ventricle. Due to a greater volume of air
absorption, symptoms of venous air embolism appeared. 12.5.6.3 Imaging Examination
Chest X-ray shows normal or bubbles in non-arterial system.
Other X-ray reveals dilatation of the pulmonary artery, a
12.5.6 Diagnosis of VAE decrease in focal blood flow (Westermark sign), and pulmo-
nary edema. Ultrasonic cardiogram helps to determine the
12.5.6.1 Symptoms and Signs presence of gas in the right ventricular blood flow and can
VAE is characterized by sudden occurrence and rapid devel- detect the tiny bubbles which cannot be located. Precordial
opment. Among the typical clinical manifestations of VAE, Doppler can quickly discover bubbles. This method is simple
the most sensitive monitoring method to detect VAE is the and can quickly find out bubbles as small as 0.12–0.25 mL. Its
precordial Doppler ultrasonography. When more air enters sound quality takes on a special high-pitched tone like “rus-
the bloodstream, the end-tidal CO2 pressure drops. The tle” or “rumble.”
determination of ETCO is highly sensitive and distinctive in
2
diagnosis of VAE. At present, CO2 level is monitored in 12.5.6.4 Electrocardiogram Examination

patients under general anesthesia, and a drop in ETCO has 2
Tachycardia, right axis deviation, right ventricular strain, and
become the most important early sign of VAE. If the patients ST segment depression might be discovered by ECG.
are at high risk prior to operation, or when difficulty arises
during operation, central venous catheter may be placed to
check and monitor the rise in intracardiac and pulmonary 12.5.7 Monitoring of VAE
artery pressure. Suction of the bubbles contributes to the
treatment of this complication. The onset of venous air embolism is so sudden and severe
that it is extremely difficult to deal with, often leading to
12.5.6.2 Laboratory Tests death and severe disability. Therefore, intraoperative mon-
Arterial blood gas analysis indicates hypoxemia, hypercap- itoring should be strengthened, including continuous pre-
nia, and metabolic acidosis. Mild symptoms may manifest as cordial Doppler monitoring, the end-tidal CO2 pressure
394
Table 12.19 Characteristics and treatments of air embolism during operative hysteroscopy
Authors Year Surgery/distention media Morbidity and treatment Outcomes
Imasogie et al. 2002 TCRE+P Improved by 100% O2 inhalation
Be in lithotomy position. At 15 min after the beginning of the procedure, Sa O2
declined to 87% and ETCO2 dropped to 27 mmHg
Fukuda et al. 2000 TCRM Forty-five minutes after the start of the surgery, the patient complained of severe Improved 20 min after im. ephedrine
back pain, with blood pressure 40 mmHg and Sa O2 80%. ECG showed atrial 5 mg
fibrillation
Corson et al. 1996 TCRA/saline Be in moderate lithotomy position. At the time of replacement of endoscopic Died
sheath, the anesthetist discovered drops of the patient in heart rate, Sa O2 and
blood pressure, and cyanosis
Corson et al. 1996 TCRS (with scissors)/CO2 Gave up treatment 10 days later and
Patient was in lithotomy position. After removal of endoscope for 2 min, Sa O2 died
and ETCO2 dropped. Gas extracted by heart puncture, followed by DIC and
renal failure
Corson et al. 1996 Diagnostic laparoscopy Patient was in extreme lithotomy position. The uterine manipulator with an Died in several minutes and autopsy
after D&C open end was used to lift the uterus. At the end of the procedure, the blood revealed air filling in four heart
pressure dropped. Convulsion with mill-wheel murmur revealed precordium. chambers
The patient was put in left lateral decubitus position. Foamy blood was
extracted by heart puncture. The emboli were confirmed to be room air from
manipulator
Corson et al. 1996 TCRE Uterine aspiration performed first. Before insertion of endoscope and opening Died
the water inflow valve, ETCO2 dropped, and cardiac arrest occurred. Central
venous catheter inserted and 15 mL of air extracted
Nachum et al. 1992 TCRE/Hyskon solution When changing the irrigation fluid bag, the pump still worked. The patient felt Died
uneasy and coughed, with heart rate 50 beats/min, followed by cyanosis and
apnea. Foaming blood was extracted by arterial catheter insertion, with Sa O2
16 mmHg. HBO therapy with transient improvement
Perry et al. 1992 HEAL/Ringer lactate After 30 min of surgery, some gas noted in the tube as irrigation bag was Recovered
solution changed. ETCO2 dropped from 34 to 22 mmHg. The operation discontinued and
100% oxygen inhalated. The ETCO2 returned to normal within 3–4 min and
surgery resumed. Again, the ETCO2 decreased from 35 to 21 mmHg with a
change in the Doppler tones characteristic of air embolism. The operation
discontinued again and 100% oxygen inhalated, with subsequent recovery
Perry et al. 1992 TCRM/1.5% glycine After 50 min of surgery, while the uterus was irrigated using a urologic bulb Transabdominal myomectomy
syringe, the Doppler sounds suddenly increased, Sa O2 decreased from 99 to
90%, ETCO2 decreased from 31 to 17 mmHg, and the blood pressure decreased
from 120/80 to 90/60 mmHg. The operation discontinued and 100% oxygen
inhalated with subsequent recovery. The operation lasted for 150 min and
hyponatremia developed
Wood and Roberts 1990 TCRE/10% glucose Laparoscopy revealed air bubbles entering small caliber veins in the lateral Complete recovered
pelvic wall. Sa O2 dropped from 97 to 84%, her pulse rate rose from 72 to
110 beats/min. The head-down position was reversed and positive pressure
ventilation started with 100% oxygen. Recovery achieved 5 min later
Baggish and Daniell 1989 HEAL, cooling with air or Five cases. Sudden gas embolism and cardiovascular collapse developed during Four died, and one survived with
nitrogen operation. Cardiac arrest occurred in four of the five women neurological deficits
E. Xia et al.
monitoring, and measurement of oxygen saturation. circulation and dispersing into the peripheral pulmonary
Ultrasonic cardiogram may be the most sensitive tech- venous system so as to restore ventricular functions. A large
nique in checking bubbles less than 0.5 mL within the amount of normal saline is injected to promote blood circula-
heart, but it has not been widely used due to its high false tion. If all measures (including closed chest massage) fail,
positive rate. Now most of patients’ surgery are performed thoracotomy can be performed for direct heart massage and
under general anesthesia with carbon dioxide graphic removal of air emboli. If it is maintainable, timely hyperbaric
monitoring. Insertion of central venous pressure catheter oxygen therapy should be followed. Even after the success-
can check and monitor whether there is a rise in intracar- ful management of VAE, the patient may suffer pulmonary
diac and pulmonary artery pressure and can suck the bub- insufficiency. VAE can appear again 30 min after air inlet
bles out, contributing to the treatment of this complication. pathway is blocked, so the patient must be sent to ICU for
Figure 12.12 shows the various methods of monitoring the further treatment.
gas into the heart and main vessels and its secondary phys- Head-down and left lateral decubitus position helps to
iological changes. Along with the entry of more gas, limit the gas to gather in the ventricular apex and prevents
abnormalities of heart and lung function may appear. the gas into the pulmonary system while maintaining the
Corson et al. thought that this risk might be reduced with right ventricular output, thus allowing bubbles in the right
more attention paid to operating skills and monitoring of ventricle to drift away from outflow tract and restore normal
end-tidal CO2 levels. cardiac dynamics. But if the bubble is too large and fills up
most of chambers, this may not work easily.
12.5.8 Emergency Managements

12.5.9 Prevention and Treatment of VAE
If air embolism is suspected, the operator should immedi-
ately stop any method causing gas injection so as to prevent Air embolism is a complication from distending media dur-
gas from entering. Then, invert head-down position and turn ing hysteroscopy. When diagnostic hysteroscopy is per-
to left-side lying position, and 100% oxygen inhalation is formed, CO2 enters the systemic circulation, leading to gas
given. For the patients with obvious dyspnea or uncontrolla- embolism. CO2 has a high solubility in plasma with absorp-
ble hypoxemia, endotracheal intubation should be con- tion rate of 68%, so it is easy to clean. Therefore, its toler-
ducted. Placement of central venous pressure catheter can ance capacity may be up to 7.5 mL/kg, and the lethal dose is
monitor intracardiac and pulmonary artery pressure. The commonly between 3 and 5 mL/kg, or about 300 mL for a
catheter can be placed in the air tank to suck the bubbles out 70-kg patient. There is a wide safety limit for CO2, so embo-
as much as possible. If cardiopulmonary failure occurs, lism occurs only when there is a long-time use of CO2 or a
immediate cardiopulmonary resuscitation should be per- high flow rate. Siegler and Valle proposed that when pressure
formed. Closed chest massage can break the bubbles and was set <200 mmHg, the flow volume <100 mL/min was
make them smaller, thus forcing them into the pulmonary safe at standard temperature and pressure. Brandner et al.
Fig. 12.12 Monitoring of Cardiovascular

VAE collapse
In clinical
In subclinical condition
condition,
Below the moderate
threshold physiological
Speed of changes
air entry ↑ value, no
physiological
changes BP ↓
changes in ECG
breathing rate ↑
CVP ↑
PaCO2 ↑
cardiac
ETCO2 ↓
output ↓
pulmonary
artery pressure ↑
Doppler
Sensitivity of various monitoring techniques ↑

396 E. Xia et al.
studied 1261 procedures of diagnostic CO2 hysteroscopies. dilatation and positioning are causative factors, the incidence
The room air from the gas supply tube (about 40 mL) was rate will be higher than it is. If a change in the cardiopulmo-
deaerated before procedures and no gas embolism occurred nary function takes place just when the operation begins, this
during procedures. This indicated that emboli that occurred indicates that air embolism may be caused by the outside air.
during CO2 hysteroscopy were caused by room air, rather If air embolism is suspected, the operator should immedi-
than CO2, so it is preventable. Brundin and Thomasson ately stop any method using gas injection so as to prevent gas
reported that metallic heart sound in the systole was detected from entry. Then, invert head-down position and insert cen-
during CO2 hysteroscopy due to the intracardiac presence of tral venous pressure catheter. If cardiopulmonary failure
free carbon dioxide in 7 women (10%) with no history of occurs, immediate cardiopulmonary resuscitation should be
cardiac valvular disease. The procedure was suspended performed. Left lateral decubitus position and closed chest
immediately and the hysteroscope was withdrawn. The massage can break the bubbles and force air into the pulmo-
metallic heart sounds disappeared soon after, and the hyster- nary circulation so as to recover ventricular functions.
oscopy continued. They suggested that monitoring with sim- Sometimes the central venous catheter can be placed in the
ple auscultation might avoid serious cardiovascular air tank to exhaust the air as much as possible. A large
complications. amount of saline is injected to promote blood circulation and
Nowadays it is believed that the gas of VAE may come hyperbaric oxygen therapy should be administered.
from the inflow pipe or from the bubbles generated by vapor- In order to detect VAE timely and rescue early, in addition
ization of tissues. The gas in the inflow pipe enters the sys- to the routine monitoring of blood pressure, heart rate, and
temic circulation through the fractured veins in the uterine oxygen saturation, it is also necessary to monitor the end-
cutting surface under the intrauterine pressure. If a certain tidal CO2 pressure. There still exist disputes over the routine
volume of air is not emptied before uterine distension, the air application of central venous catheter and the diagnostic
may enter the circulatory system at the early stage of opera- ultrasonography.
tion. Such a small amount as 20 mL of air may produce
response, so attention should be paid to emptying the gas in
the inflow pipe at the time of operation. When intrauterine 12.6 Intrauterine Adhesions
pressure exceeds venous pressure, asymptomatic, symptom-
atic, and fatal air embolism may appear, and the risk of air Dan Yu
embolism will increase as the intrauterine pressure rises.
Nowadays, scholars have tended to reach an agreement in Intrauterine adhesion is a major late postoperative complica-
prevention of air embolism. Effective prevention is to aim at tion of hysteroscopic surgery and may occur following all pro-
the cause of disease, mainly around how to block the source cedures. The severity of reformed adhesions and the likelihood
of intrauterine air, reduce the exposure of vascular surface, of that happening are closely related to the degree and the prop-
minimize the intrauterine pressure, and strengthen monitor- erty of previous intrauterine lesions, as well as the extent of
ing. The specific measures include: When at a head-down tilt surgical cutting. A second-look hysteroscopy in early postop-
position, the heart and vena cava should be avoided being erative period is a cost-effective method of diagnosing and
lower than the level of uterus; attention should be paid to loosening new adhesions following hysteroscopic surgery.
emptying the air in the irrigation pipe before operation; the
cervical canal should be carefully dilated so as to avoid
injury or partial penetration into the muscular wall, whose 12.6.1 Incidence of Postoperative Intrauterine
vascular network can allow air in; for nonporous women or Adhesions
women with previous history of cervical surgery, the osmotic
dilator is used so as to reduce trauma; after cervical dilata- 12.6.1.1 Hysteroscopic Endometrial Surgery
tion the vagina should be closed or wet gauze is used to tam- Hysteroscopic resection or ablation of endometrium usually
pon the cervix so as not to expose the cervix in the air; before leads to different degrees of intrauterine adhesions.
the operator is ready to insert the hysteroscope, the last dila- Hysteroscopic endometrial surgery destroys both the basal
tor must be placed in the cervical canal all the time. The risk layer of endometrium and the superficial layer of myome-
of air embolism increases as the intrauterine pressure rises, trium, which causes the denuded surfaces in the cavity adher-
so the effective minimal uterine pressure should be chosen at ing to each other so that intrauterine adhesions are developed.
the time of operation. The flow rate of CO2 should be con- In the early stage of the application of hysteroscopy,
trolled below 100 mL/min, and the intrauterine pressure can- Montagna et al. used second-look hysteroscopy to observe
not be higher than 200 mmHg. Corson reported that air the uterine cavity after endometrial ablation. They found the
embolism occurred in a case at a supine position. Therefore, uterine cavity becomes smaller in all cases, with different
at least positioning is not the only causative factor. If difficult degrees of adhesions visible. Prof. Xia from the Hysteroscopy
Center of Fuxing Hospital, Capital Medical University car- In recent years, with the development of hysteroscopic
ried out a study on second-look hysteroscopy in 26 patients surgical techniques, except for TCRS, more and more women
after hysteroscopic endometrial resection. Different degrees who have other congenital uterine dysplasia such as bicornu-
of shortened cavity and the fibrosis of uterine walls were ate uterus, unicornuate uterus, or T-shaped uterus, etc., apply
detected in all patients. hysteroscopic surgery for treatment and may produce post-
A variety of global endometrial ablation, i.e. second gen- operative adhesions.
eration endometrial ablation, can also destroy the whole
layer of endometrium and partial superficial layer of myo- 12.6.1.4 Hysteroscopic Lysis of Intrauterine
metrium, which results in the formation of postoperative Adhesions
intrauterine adhesions. Leung et al. reported that, after ther- Intrauterine adhesions are prone to recurring after hystero-
mal balloon endometrial ablation, the occurrence rate of scopic adhesiolysis. In cases with initial intrauterine adhe-
intrauterine adhesions was 36.4% (8/22). Luo et al. analyzed sions, the endometrium becomes fibrosis with poor ability of
53 cases of microwave endometrial ablation and reported the regeneration. By hysteroscopic lysis of adhesions, the
occurrence rate of postoperative adhesions 52.8% (28/53). denuded myometrium in the dissected surface of the cavity is
hard to be covered by epithelium, but is prone to cohering
12.6.1.2 Hysteroscopic Resection of Myomas and forming adhesions. It was reported in literature that the
Just like endometrial ablations, hysteroscopic resection of recurrence rate of the adhesions after hysteroscopic adhe-
myomas destroys the endometrium and may produce adhesiolysis ranged from 3.1 to 76%, and it was much higher in
sions after the procedure. Many scholars reported the occur- cases with severe adhesions (from 20 to 62.5%), which is
rence of intrauterine adhesions after hysteroscopic resection shown in Table 12.21.
of myomas, which was shown in Table 12.20.
12.6.1.5 Other Hysteroscopic Surgeries
12.6.1.3 Hysteroscopic Surgery on Uterine Intrauterine adhesions may be induced following other hys-
Malformations teroscopic surgeries, such as resection of endometrial pol-
Adhesions may be produced following hysteroscopic resec- yps, resection of retained conceptional products, removal of
tion of uterine septum and are usually found in the fundus intrauterine foreign bodies, etc. In a clinical study reported
and the anterior or posterior walls of the cavity. In a clinical by Guida et al., TCRP was performed in 33 cases, with IUA
study reported by Guida et al., the adhesions occurred in occurring in 6 (18.2%). Fuchs et al. reported that the inci-
three cases (37.5%) after eight cases of TCRS. Yang et al. dence of moderate and severe adhesions was 14% after hys-
reported that the incidence of the adhesions after TCRS was teroscopic resection of retained products of conception in
88% (14/16). uterine cavity.
Table 12.20 The incidence of intrauterine adhesions after hysteroscopic resection of myomas
Authors Year Time of second-look hysteroscopy No. of cases No. of cases with adhesions Incidence (%)
Taskin et al. 2000 2–4 weeks 22 (single) 8 36.4
13 (multiple) 6 46.2
Guida et al. 2004 3 months 24 8 33.3
Yang et al. 2008 1–3 months 132 2 1.5
Touboul et al. 2009 2 months 53 4 7.5
Yang et al. 2013 1 month 65 26 40
Table 12.21 The incidence of intrauterine adhesions after hysteroscopic adhesiolysis

Preoperative intrauterine adhesions Preoperative severe adhesions
No. of cases with
postoperative No. of cases with
Authors Year No. of cases recurrence Incidence (%) No. of cases postoperative recurrence Incidence (%)
Valle and Sciarra 1988 187 44 23.5 47 23 48.9
Pabuccu et al. 1997 40 8 20 10 6 60
Capella-Allouc 1999 – – – 16 10 62.5
et al.
Preutthipan and 2000 65 2 3.1 10 2 20
Linasmita
Yu et al. 2008 61 17 27.9 31 13 41.9
Yang et al. 2013 45 34 76 – – –
398 E. Xia et al.
12.6.2 Mechanisms of Occurrence 12.6.3.2 Pregnancy Disorders

of Postoperative Intrauterine Hysteroscopic endometrial ablation has an effect on artificial
Adhesions contraception. But postoperative conceptions were still
reported in literatures. TCRE may destroy the whole endo-
Uterus is a potential hollow organ, and under normal circum- metrial layer, then the dissected surfaces heal with scar tis-
stances, even though the anterior and the posterior walls are sues; therefore, the outcomes in patients who conceive
close to each other, adhesions will not happen. This is because following TCRE are commonly not good. Failure of
the endometrium has a very strong ability of regeneration operation may happen when performing termination of preg-
under the action of ovarian hormones. In cases of intrauterine nancy. Prof. Xia from the Hysteroscopy Center of Fuxing
operation within a small area, as long as the basal layer of Hospital, Capital Medical University summarized the out-
endometrium is not damaged, or even if part of the basal layer comes of 39 conceptions after TCRE in 1621 cases. The
is damaged but the opposite endometrial layer is intact and pregnancy disorders and poor outcomes discovered included
without rough surfaces, the damaged areas of the endome- tubal pregnancy, cornual pregnancy, cervical pregnancy, suc-
trium can be quickly repaired by regeneration of the endome- tion evacuation failure, hemorrhage following suction, pla-
trium, thus, the formation of adhesions will not occur. centa implantation, hysterectomy, etc.
The procedures of hysteroscopic endometrial ablation Because of the presence of intrauterine adhesions, after
extensively destroy the basal layer of endometrium and the TCRM, TCRS, TCRA, or TCRP, the patients who wish to
superficial layer of myometrium. The absence of the basal become pregnant and produce adhesions may have infertil-
layer leads to the disorder of endometrial re-growth, so some ity, and patients who achieve conception may have miscar-
surfaces of the cavity are replaced by fibrotic scar tissues. riage, preterm delivery, placental disorders, etc.
Furthermore, the denuded surfaces in uterine cavity adhere
to each other before they can be covered by the proliferated 12.6.3.3 Hematometra
epithelium and are easy to cohere and form adhesive bands When intrauterine adhesions occurring after hysteroscopic
which obliterate the cavity. surgery obliterate the cervical os or uterine cavity partially or
Other types of hysteroscopic surgeries also can destroy totally, hematometra may develop. The patients may present
the basal layer of endometrium and expose the myometrium with periodic lower abdominal spasmodic pain, coexisting
of the uterus. The denuded surfaces, especially if they are with amenorrhea or hypomenorrhea. After hysteroscopic
opposite to one another, adhere together and form adhesions. endometrial ablation, the dissected surface is repaired by
When the denuded surface is concurrent with infections in scar tissue, and new adhesions can separate the cavity into a
uterine cavity, intrauterine adhesions are more easily few spaces. The residual endometrial island in scar tissues
developed. proliferates and exfoliates along with the cyclic changes of
hormones, which lead to the blood gathering in the cavity
and being unable to be drained off. For other hysteroscopic
12.6.3 Symptoms of Postoperative surgeries, new adhesions also can be developed to occlude
Intrauterine Adhesions part of the cavity, with normal endometrium in uterine cavity
proliferating and exfoliating cyclically, leading to the blood
The clinical symptoms are diverse in patients who develop gathering in the cavity and the formation of hematometra.
intrauterine adhesions after hysteroscopic surgery. Patients For those women who have also underwent tubal steril-
with mild adhesions usually present with no symptoms and ization, after TCRE, intrauterine adhesions occurred may
generally are not easy to be diagnosed. When more endome- occlude the uterine cavity. So the menstrual blood being pro-
trium is destroyed, the patients may present with menstrual duced by the residual endometrium in the areas of bilateral
disorders. Patients who produce adhesions and want to have uterine cornua cannot be discharged through the fallopian
children may present with infertility. Patients who conceive tubes, but accumulates in the space of uterine cornua, which
might have complications such as spontaneous miscarriage, leads to periodical abdominal pain and was named “post-
preterm delivery, placenta adhesion, postoperative bleeding, ablation-tubal sterilization syndrome” (PASS).
etc. When the adhesions occlude the uterine cavity, hemato-
metra may occur, which leads to periodic abdominal pain.
12.6.4 Diagnosis of Postoperative Intrauterine
12.6.3.1 Menstrual Disorders Adhesions
According to different degrees of endometrial destruction
after hysteroscopic surgery, the patient may present with Patients who get intrauterine adhesions after hysteroscopic
hypomenorrhea, prolonged and light bleeding, oligomenor- surgery can be presumptively diagnosed by their history and
rhea, or amenorrhea. clinical manifestation. Patients who are suspected of hema-
tometra may have gynecologic ultrasonography scanning to 12.6.4.2 Second-Look Hysteroscopy

identify irregular-shaped low echoes in uterine cavity. The Second-look hysteroscopy after hysteroscopic surgery can
accurate diagnosis of intrauterine adhesions depends on a inspect the uterine cavity, identify the intrauterine adhesions,
second-look hysteroscopy. and determine the diagnosis of the adhesions under direct
vision. When the adhesions occlude the cavity, hysteroscopy
12.6.4.1 Gynecologic Ultrasonography can only show a partial cavity below the level of the
Gynecologic ultrasonography may scan the uterus in the lon- adhesions.
gitudinal and the transverse planes, including inspection of Under second-look hysteroscopy after hysteroscopic
the contour of the uterus, the echoes of uterine walls, the endometrial ablation, the normal shape of the cavity has dis-
echo of the endometrium, and the shape of the cavity. This appeared, with its length shortened, its fundus narrowed, and
has been a primary screening method for diagnosis of intra- the walls fibrosed. The shape of the cavity is shown as “tubi-
uterine adhesions. form,” and sometimes constricting rings can be seen. The
In patients with intrauterine adhesions after hysteroscopic endometrium is present as filmy and faint or as fibrous bands
surgery, by ultrasonography scanning, the echoes of endo- (Fig. 12.15).
metrium may appear thin, uneven, discontinuous, echolu- The characteristics of intrauterine adhesions after hys-
cent, or without periodical changes (Fig. 12.13). In patients teroscopic resection of myomas are always determined by
with the damage of endometrium being more serious, it the locations, sizes, and numbers of the myomas preopera-
might be difficult to display an endometrial echo and hard to tion and mostly are fibrous adhesive bands which involve the
distinguish it from surrounding myometrial echoes. anterior and posterior walls (Fig. 12.16a, b).
When the adhesions block the cavity and produce hema- After hysteroscopic resection of uterine septum, intrauter-
tometra, intrauterine adhesions divide the cavity into a few ine adhesions are usually formed vertically from previous
spaces with different sizes, and menstrual blood accumulates dissected surfaces, locating in the middle of the fundus or on
in these spaces where the endometrium remains. Under the anterior or posterior walls (Figs. 12.17a, b and 12.18). In
ultrasonography scanning, echolucent or low echo areas may patients with intrauterine adhesions occurring after hystero-
be identified (Fig. 12.14). scopic resection of other types of uterine malformations, the
Fig. 12.13 The longitudinal scanning of the uterus by ultrasonography

1 month after hysteroscopic adhesiolysis. It shows a moderate and Fig. 12.14 The longitudinal scanning of the uterus by ultrasonography
uneven echo of the endometrium with its thickness 7 mm. The continu- 3 months after hysteroscopic adhesiolysis. It shows a moderate and
ity of the endometrium is interrupted, and the areas with low echoes uneven echo of the endometrium, with its continuity interrupted.
indicate new adhesion bands Echolucent area is shown in the fundus
400 E. Xia et al.
uterine cavity may be narrow, with the top of the cavity After hysteroscopic adhesiolysis, the recurrence of intra-
occluded, and the adhesions may block both cornual areas uterine adhesions may show a variety of presentations, such
(Fig. 12.19a, b). as the reformation of the adhesions from the area of the origi-
nal adhesions which has been divided or formation of new
adhesions from other traumatic areas (Figs. 12.20 and 12.21).
12.6.5 Prevention of Postoperative

Intrauterine Adhesions
For patients who are prone to having intrauterine adhesions

after hysteroscopic surgery, some measures are taken during
and following operations to prevent the formation of intra-
uterine adhesions.
12.6.5.1 Reduction of the Surgical Trauma

During Hysteroscopic Surgery
The cutting of hysteroscopic endometrial resection should
stop above the level of cervical os, to avoid the injury to cer-
vical canal. Trauma to cervical canal may lead to cervical
atresia and hematometra.
Procedures of other types of hysteroscopic surgery should
try to minimize the extent and the depth of injury to endome-
trium so as to avoid too large areas of injured surface in uter-
ine cavity. If more fibroids are in the cavity, complete
Fig. 12.15 Second-look hysteroscopy after hysteroscopic endometrial
ablation. The uterine cavity presents a narrowed shape, with the endo- resection of myomas through primary operation will lead to
metrium being filmy and pale too large areas of dissected surface and is prone to develop-
a b
Fig. 12.16 Second-look hysteroscopy 9 months after hysteroscopic adhesion produced from the previous dissected surfaces between ante-
resection of multiple myomas. The normal shape of the cavity is disap- rior and posterior walls. (a) Image with close view. (b) Image with far
pearing and a vertical adhesive band is seen on the left, which is the view
a b
Fig. 12.17 Second-look hysteroscopy 4 years after hysteroscopic resection of uterine septum. (a) The uterine cavity is near normal, with both
tubal ostia visible. (b) Close view of the fundus, with vertical scars seen
ing postoperative intrauterine adhesions. In this situation,

multiple procedures may be conducted. Partial resection of
intrauterine myomas is performed during the first operation,
and the complete resection is performed by repeated opera-
tions after the recovery of the dissected surface.
Selection of a suitable hysteroscopic instrument may also
reduce the surgical injury to endometrium. Operations
without energy sources such as scissors and biopsy forceps
may achieve precise incisions and avoid the injury to endo-
metrium caused by energy sources. Hysteroscopic electro-
surgery can resect the lesions precisely and stop the bleeding
effectively, but the thermal damage caused by energy surgery
can induce the formation of scar tissues and the injury to
adjacent normal endometrium, which results in the forma-
tion of adhesions.
12.6.5.2 Artificial Cyclic Hormone Treatment

After Hysteroscopic Surgery
A certain dose of sex hormone treatment after hysteroscopic
surgery can stimulate the proliferation of endometrial glands
and stroma, which accelerates the repair of endometrium. So
Fig. 12.18 Second-look hysteroscopy 2½ years after hysteroscopic
artificial cyclic treatment with sex hormones, which enhances
resection of uterine septum. The left wall in the cavity constricts, with the re-growth of endometrium, has become a common adju-
visualization of vertical adhesive bands between the anterior and poste- vant therapy for hysteroscopic surgeries, such as the resec-
rior walls of the cavity tion of uterine septum, the lysis of adhesion, etc. A routine
402 E. Xia et al.
a b
Fig. 12.19 Second-look hysteroscopy 2 years after hysteroscopic with the endometrium being thin. (b) Close view of the cornual area.
metroplasty of right unicornuate uterus. (a) The cavity is narrow- The tubal ostium is invisible, with vertical mild adhesive band
shaped, with the top of the cavity occluded. The cavity is to the right, visualized
Fig. 12.20 Second-look hysteroscopy 2 years after hysteroscopic

adhesiolysis. The shape of the cavity is distorted as narrow-shaped,
with the top of the cavity occluded and adhesive band visualized Fig. 12.21 Second-look hysteroscopy 4 months after hysteroscopic
adhesiolysis. The shape of the cavity is distorted, with vertical adhesive
bands in the fundus and on left lateral wall. The endometrium is thin
and pale
regime is the use of a sequential therapy of estrogen and pro- hysteroscopy is needed so as to restore the normal shape of
gesterone for 2 or 3 cycles, with estrogen 4 mg/day for 4 the cavity and expose bilateral tubal ostia, as well as avoid
weeks, and the addition of progesterone in the last 2 weeks the damage to normal endometrium.
of the treatment cycle. It is easy to develop recurrent adhesions after lysis of
intrauterine adhesions, so adjuvant measures, such as cyclic
12.6.5.3 Intrauterine Insertion of Barriers After hormone treatment and intrauterine placement of IUD,
Hysteroscopic Surgery should be conducted following adhesiolysis. A second-look
At the end of hysteroscopic procedures such as the resection hysteroscopy may be performed to divide the reformed adhe-
of septum, the lysis of adhesions, etc., intrauterine insertion sions in the early postoperative period.
of an IUD for 1–3 months, concurrent with the administra-
tion of cyclic hormone treatment, is a common used therapy 12.6.6.1 Division of Adhesions During Second-
to promote the healing of injured surfaces and prevent the Look Hysteroscopy Under
formation of adhesions. Ultrasonography Guidance
Some scholars attempted intrauterine instillation of ACP The mild and loose intrauterine adhesions may be divided by
gel after hysteroscopic surgery to prevent the formation of diagnostic hysteroscope during second-look hysteroscopy.
intrauterine adhesions. Guita et al. studied the use of For those patients who have adhesions in cervical os after
Hyalobarrier gel at the end of hysteroscopic surgeries includ- hysteroscopic surgery, the probe may be applied to investi-
ing the resection of myomas, polyps, and septa. Second-look gate the uterine cavity under abdominal ultrasonography
hysteroscopy was applied to detect the formation of postop- guidance. After the drainage of dark red or coffee-like old
erative intrauterine adhesions. The incidence of the adhe- blood, Hegar dilators can be used to dilate the cervix to No.
sions was found to be 10.44% (7/67) in patients with ACP 6 or 7, and then diagnostic hysteroscopy is performed to
gel and was 26.2% (17/65) in the control group (P < 0.05). inspect the uterine cavity. Antibiotics should be administered
postoperatively to prevent infections.
12.6.5.4 Prophylactic Antibiotics
The routine use of antibiotics is not usually recommended 12.6.6.2 Hysteroscopic Lysis of Adhesions
for preventing infections following hysteroscopic surgery. In If intrauterine adhesions are too thickened to be divided by
patients with the use of IUD or ACP gel, broad-spectrum diagnostic hysteroscope, operative hysteroscopy can be con-
antibiotics should be routinely used to prevent infections. In ducted to excise the adhesions. Usually it uses wire loop
general, it is taken for 3–7 days. electrode to cut or the needle electrode to divide under direct
vision. Adhesions which are formed following hysteroscopic
12.6.5.5 Second-Look Hysteroscopy After endometrial resection are mostly fibromuscular adhesions.
Hysteroscopic Surgery Due to the extensive areas of adhesions and insufficient iden-
The crucial healing period of the injured surfaces after hystero- tifications of endometrium, the dividing process must be
scopic surgery is 1–2 months postoperatively. When the with- guided by ultrasonography so as to avoid undue injury to
drawal bleeding is stopped after 1–3 months of hormone uterine walls caused by blind division. This undue injury
treatment, a second-look hysteroscopy may be conducted, and might result in massive intraoperative bleeding or uterine
new filmy adhesions can be divided simultaneously and perforation. It should be noted that the purpose of dividing
mechanically by hysteroscope, but moderate and severe adhe- intrauterine adhesions after TCRE is not to reconstruct the
sions must be dissected by operative hysteroscopy afterwards. uterine cavity but to release the uterine hematometra or fluid
accumulation and then to alleviate periodical abdominal
pain. In the process of division, there is no need to expose the
12.6.6 Treatment of Postoperative Adhesions bilateral fallopian tubal openings, but is enough to have the
residual hematometra released completely.
For hysteroscopic endometrial ablation and other types of For patients who develop intrauterine adhesions after
hysteroscopic surgeries in women without the desire to TCRM, TCRP, TCRS, and TCRA, if they wish to become
become pregnant, the postoperative adhesions should be pregnant, attention should be paid to restoring a normal cav-
managed only when the woman has developed clinical ity, opening both tubal ostia, and trying to avoid the destruc-
symptoms. The therapy regimes include dividing the adhe- tion of normal endometrium. Details of operative procedures
sions of the uterine cavity, draining the hematometra and can be seen in Sect. 9.6 of Chap. 9.
fluid accumulation in uterine cavity, and reducing the peri-
odical abdominal pain. 12.6.6.3 Hysterectomy
For patients who want to get pregnant and have intrauter- Hysterectomy may be considered in the conditions that if all
ine adhesions following hysteroscopic surgery, an operative the above therapies are ineffective, if there are thickened and
404 E. Xia et al.
extensive adhesions in the cavity, or if the patients have ses. Therefore, there are patients occasionally with postop-
severe dysmenorrhea due to hematometra in the areas of fal- erative pregnancy in clinical practice, which may be
lopian tubal ostium. intrauterine or ectopic pregnancy with the occurrence rate of
0.7–2%. Xia et al. from the Hysteroscopy Center of Fuxing
Hospital, Capital Medical University, analyzed 1341 TCRE
12.7 Postoperative Pregnancy procedures from May 1990 to November 2001 with a follow-
up of 3 months to 11 years and 6 months. There were 32
Enlan Xia pregnancies in 26 patients after operation with the occur-
rence rate of 2.39%. Among 32 pregnancies, there was one
In the early stage of application of TCRE technique, it was cervical pregnancy, two tubal pregnancies, and one right cor-
thought that the implantation of fertilized eggs was difficult nual pregnancy. Among 28 intrauterine pregnancies in 22
due to the postoperative uterine scarring after TCRE, so women, there were three pregnancies in two women and two
patients who do not require fertility are listed as operative pregnancies in two women. Its occurrence was related to the
indications. In 1990, Skar and Nesheim reported that TCRE age of the patient, the ability of endometrial regeneration,
technique might be used for contraception. However, with and the depth and extent of endometrial resection. The prob-
the wide application of this procedure, there are more and ability of intrauterine pregnancies was decreased with the
more reports about pregnancy after TCRE and EA. Greater extension of postoperative duration. Among pregnancies fol-
difficulty in induced abortion for postoperative pregnancy lowing TCRE, 62.5% occurred within the first year, 21.88%
and more obstetric complications occurring in pregnant in the second year, 9.38% in the third year, and 3.11% in both
women after hysteroscopic surgery should attract the atten- the fourth and fifth years. Of them, 7% occurred in the first
tion of the doctors and patients. 100 procedures, and among the rest 1241 procedures, post-
operative pregnancy rate fell to 1.69%. The higher rate of
occurrence in the first 100 procedures was obviously related
12.7.1 Possibility of Pregnancy After TCRE to shallow resection of endometrium in the initial stage of the
application of the procedure. The second generation endo-
Although postoperative pregnancy after EA is rare, it is pos- metrial ablation is safe and easy to operate compared with
sible. Kir and Hanlon-Lundberg calculated that the preg- TCRE procedure, but in recent years its postoperative preg-
nancy rate after endometrial ablation was 0.24–0.68%. It has nancies have also been reported. Ismail et al. reported on one
been reported that due to the narrowed and scarred cavity case of intrauterine pregnancy after thermal balloon endome-
following endometrial surgery, pathologic placental adher- trial ablation. In 1992, Whitelaw and Sutton first reported on
ence and fetal demise developed in postoperative pregnant ectopic pregnancy after TCRE. Dicker et al. reported on five
woman. In theory, the resected endometrium cannot regener- cases of cervical pregnancy and held that its etiology was
ate and there should be long-term contraceptive effects. related to the damage to the endometrium caused by induced
DeCherney et al. reported that two cases died of medical dis- abortion and traumatic curettage. Two of five cases had
eases within half a year after operation, and autopsy revealed severe intrauterine adhesions, which produced partial or total
that the endometrium was completely replaced by collagen occlusion of the uterine cavity, and this kind of adhesion
scar tissues. Magos et al. reported that second-look hysteros- might be an important cause of cervical pregnancy.
copy was performed at the third and 12th month after opera- In short, endometrial resection/ablation does not mean
tion in 68 cases which revealed a small uterine cavity and sterilization and also cannot ensure sterilization. In addition,
fibrotic endometrium. However, since the ability of endome- those with no menstruation are still likely to conceive; there-
trium to regenerate is amazing, the anatomic morphology of fore, we should have a due and sufficient understanding of
uterine cornua is invaginated and histological structure of pregnancy after endometrial ablation and advocate contra-
muscle wall is thin, perforation of the uterus may occur eas- ception in patients after operation. The doctors should warn
ily. Uterine fundus is located in the upper portion of uterus, the patients who had amenorrhea, dripping bleeding and
the wire loop electrode is needed to do the transverse cutting, abdominal pain of the possibility of intrauterine and ectopic
which is difficult technically. The endometrial ablation by pregnancy.
electroresection or rollerball electrocoagulation is usually
not complete, so if the residual endometrium retains or
regenerates, intrauterine pregnancy is possible. Turnbull 12.7.2 Risk of Pregnancy After TCRE
et al. studied the uterus using MRI after endometrial resec-
tion in 59 women, of whom 22 were amenorrheic. The results 12.7.2.1 Abnormal Placenta Implantation
showed that residual endometrium was in all except three After endometrial resection, due to lack of decidual mem-
cases, but not all those with residual endometrium have men- brane support, the fertilized egg is likely to result in first-
trimester miscarriages. Goldberg, McLucas, Mints, and other TCRE was 12.8% (5/39) of all pregnancies. There were
scholars have had reports about spontaneous miscarriages of severe intrauterine adhesions in two cases of cornual preg-
pregnancy after TCRE or EA procedure. During late pregnancy and one case of suspected cornual pregnancy, produc-
nancy, the disorder of blood supply to placenta can cause pla- ing partial uterine cavity occlusion, which might be the
cental development and implantation abnormalities, major cause of cornual pregnancy and ectopic pregnancy. In
intrauterine fetal growth retardation and intrauterine fetal 2007, Giarenis et al. reported on one case of cervical preg-
death, and abnormalities of the third stage of labor. Kucera nancy after EA, who was cured with conservative treatment
et al. reported that severe complications of postoperative by ammonia armor pterin.
pregnancy after EA and TCRS occurred in three cases. In the
first case, pregnancy occurred after TCRS and uterine rupture 12.7.2.3 High-Risk Population Related
occurred in the second stage of labor. In the other two cases, to Induced Abortion
one case each occurred after TCRS and EA, respectively, and Most induced abortions after TCRE can be uneventfully per-
heavy bleeding occurred during the middle of pregnancy. formed, but they are also likely to encounter difficulties. In a
Maouris reported on one case of pregnancy who underwent follow-up of 28 cases of induced abortion in the Hysteroscopy
cesarean section at 30 weeks of gestation due to abnormal Center of Fuxing Hospital, Capital Medical University, one
fetal position and premature rupture of fetal membranes, with case was transferred from another hospital due to a failed
partial adhesions between the placenta and the fundus. In the induced abortion and a diagnosis of right cornual pregnancy.
Hysteroscopy Center of Fuxing Hospital, Capital Medical All 28 cases underwent electric suction curettage smoothly
University, one woman had amenorrhea achieved within 2 with difficulties occurred in 4. The first case was 32 years
years after TCRE, followed by oligomenorrhea. After about 6 old, who had only periodical dripping bleeding for more than
months of amenorrhea, a grossly distended abdomen was 1 year after TCRE and was transferred to our hospital due to
present, and ultrasonography indicated intrauterine preg- a failed induced abortion and diagnosis of right cornual preg-
nancy for about 6 months. At 39 weeks of gestation, a female nancy in another hospital. Gynecological examination
liveborn infant was delivered by cesarean section, weighing showed an enlarged uterus with 8 weeks of gestation, and
about 2500 g. Subtotal hysterectomy was conducted due to hysteroscopy revealed intrauterine adhesions and stenosis
deep implantation of the placenta into the uterine myome- 4 cm away from the cervical os. A 7 mm resectoscope with a
trium. Placenta increta was confirmed by histopathology. closed-loop electrode was used to move forward along the
More seriously, there is the obstetric risk of uterine rupture longitudinal axis of uterus under ultrasonography guidance
after hysteroscopic electroresection. There have been nine with the incision of the adhesive tissues about 2 cm deep, so
cases reported in recent literature. Although none of them as to move the fetal sac into the uterine cavity and be fol-
occurred following endometrial ablation, the electroresection lowed by suction curettage. The second case was 38 years
injury should be obstetric risk factors for uterine rupture. The old, who had TCRE 4 years ago and suffered hypomenorrhea
scarred and narrowed cavity after TCRE is quite similar to after operation. She underwent electric suction curettage
that of Asherman syndrome. Friedman et al. reported that after 59 days of amenorrhea. Gynecological examination
severe obstetric complications of intrauterine adhesions are revealed the uterus was enlarged to a size consistent with 8
preterm birth (12%), placenta increta, sacculated uterus, and weeks of pregnancy. Preoperative laboratory tests results: Hb
uterine dehiscence. Intrauterine adhesion after TCRE may 115 g/L; bleeding time 2 min; coagulation time 4 min; plate-
obstruct the implantation of fertilized eggs, leading to ectopic let 143 × 109/L; blood HbsAg(+); anti-HBc (+). There was
pregnancy. If the ruptured ectopic pregnancy cannot be heavy arterial bleeding after the gestational sac was aspirated
detected and treated timely, intraperitoneal bleeding is likely totally. Cervical injection of oxytocin and combined use of
to threaten life. So patients with postoperative pregnancy hemostat for hemostasis obtained little effectiveness. The
after TCRE should be considered as high-risk population. total amount of bleeding was up to 700 mL with a drop in
blood pressure. A 16Fr Foley balloon was inserted into the
12.7.2.2 High Incidence of Ectopic Pregnancy uterine cavity, and after injection of 13 mL of sterile saline
Xia et al. made a retrospective analysis of 1621 cases who into the balloon, the bleeding was arrested. The third case
had DUB, were unresponsive to medication, and had no was 42 years old, who had TCRE and TCRP 1 year and 5
desire for future pregnancy. All women underwent TCRE months ago. She suffered hypomenorrhea after operation.
from 1990 to 2005 with a follow-up of 1–14 years and 8 Ultrasonography indicated intrauterine pregnancy after 40
months. There were 39 pregnancies in 32 women, of which days of amenorrhea. But when electric suction curettage was
there were five ectopic pregnancies, including one cervical performed, only a small amount of decidual and villous tis-
pregnancy, two tubal pregnancies, one right cornual preg- sues were aspirated by suction with the pathological report
nancy, and one left cornual pregnancy, and they were all being decidua and highly secretory endometrium and pla-
cured by operation. The ectopic pregnancy rate following cental villus. Intraoperative ultrasonography revealed that
406 E. Xia et al.
there was a dark area of fluid about 3.5 cm × 2 cm in proxi- lyzed, with hypomenorrhea in one cervical pregnancy, two
mal right posterior wall, which could not be touched by a tubal pregnancies, and one right cornual pregnancy. Among
probe or a suction tube. The vaginal color Doppler performed 32 pregnancies in 26 women, hypomenorrhea occurred in
5 days later suggested that the uterus was two women with three pregnancies; in two women with two
7.7 cm × 6.8 cm × 4.8 cm, and the gestational sac was visible pregnancies, one case had postoperative hypomenorrhea,
in the right posterior wall with the size 4.3 cm × 1.6 cm, in and the other had no menstruation for 6 months after
which fetal bud and fetal heart beating rhythmically were induced abortion and became pregnancy again; in 24
visible, and the distance between the outer brim of gesta- women each with one pregnancy, 14 cases had postopera-
tional sac and serosa was only 1.8 mm. Two days later, sub- tive hypomenorrhea, six cases had no menstruation within
total hysterectomy was performed, with the right uterine 3–6 months after operation and small amount of period
cornu detected outward-protruding. A “Y-shape” incision afterwards, three cases had amenorrhea for 7 months to 2
was made in the anterior wall of the uterine corpus, with years after operation and irregular or small amount of
fibrous scar in the uterine cavity, adhesions near the fundus, period thereafter, and one case had amenorrhea within 3
endometrium visible in the bilateral cornua, and a gestational months after operation and developed pregnancy shortly
sac about 3.5 cm in diameter seen at the right cornua with a thereafter. The change in menstruation led to difficulty in
thickness of 5 mm between the outer brim and serosa. The timely diagnosis during the early pregnancy, so the early
fourth case was 40 years old, who had the third pregnancy diagnosis of pregnancy after TCRE depends on careful
complicated by multiple fibroids after TCRE. She developed attention of doctors and patients to pregnancy and the regu-
acute abdominal pain and low fever after 62 days of amenor- lar follow-up.
rhea. She had a uterus about 11 weeks of pregnancy, diag-
nosed as early pregnancy complicated by uterine fibroid red 12.7.3.2 Management
degeneration. Electric suction curettage was performed Generally, the patients who accept TCRE procedure have
under intravenous anesthesia. Due to obliteration from intra- no desire for future pregnancy. If pregnancy occurs, mostly
uterine scar and myomas, the uterine cavity became bended it will end up in induced abortion. Therefore, both the hos-
with a depth of 13 cm. The gestation sac was aspirated by pitals and doctors receiving patients should be well pre-
suction under the guidance of ultrasonography and abdomi- pared to deal with a variety of difficult conditions during
nal pain disappeared after operation. induced abortion. The location of gestational sac must be
During induced abortion in pregnant women after TCRE, accurately determined by ultrasonography prior to opera-
heavy hemorrhage, intrauterine adhesions, cornual preg- tion, and the difficulty of the operation should be estimated
nancy, and even cervical pregnancy may be encountered. The through a careful observation of uterine cavity. For patients
contracture of uterine scars may cause the distortion of uter- with obscure uterine lining or migrated gestational sac, it is
ine cavity. Even with ultrasonography intervention, it is very better to perform the cervical catheterization before opera-
difficult for a probe or suction tube to uneventfully enter the tion, administer anesthesia during operation, and carry out
uterine cavity. If cervical pregnancy is not diagnosed before suction aspiration under ultrasonography monitoring. If the
operation and curettage is performed hastily, the bleeding insertion of the probe or the suction tube is difficult, diag-
after curettage is often difficult to control. Therefore, the sur- nostic hysteroscopy can be performed to inspect the cervi-
gical history of TCRE should be regarded as risk factors for cal canal and the uterine cavity. If stenosis, adhesion, or
induced abortion. distortion occurs, incision under ultrasonography guidance
can make the uterine cavity unblocked. Hysteroscopy can
be performed to check whether the embryo is aspirated by
12.7.3 Diagnosis and Management suction completely or not at the end of the procedure. There
of Pregnancy After TCRE is profuse bleeding at the end of suction evacuation in the
second case mentioned above. In order to avoid removal of
12.7.3.1 Diagnosis the uterus, Foley balloon compression is an effective alter-
There may be improvement in menstruation after TCRE, native before implementation of radical therapy. After ter-
which may be amenorrhea, spotting, hypomenorrhea, nor- mination of pregnancy in the fourth case, abdominal pain
mal menstruation, and oligomenorrhea, and could also be disappeared.
different forms of transition like from menstruation to Baumann et al. first reported on a successful pregnancy
amenorrhea or from amenorrhea to menstruation, and there with good outcomes after tubal sterilization by bipolar coag-
may also be dripping bleeding during the transition period. ulation and TCRE. Pugh et al. reported on a viable pregnancy
In the Hysteroscopy Center of Fuxing Hospital, Capital after EA. Pinette et al. reported on a successful pregnancy
Medical University, the patients’ menstruations from the after YAG laser ablation. There is also report about treatment
time after TCRE to the time before pregnancy were ana- of infertility with TCRE. Cravello et al. reported that endo-
metrial ablation was performed in patients with AUB who tion of the fallopian tubes, and acute and chronic myometritis.
failed in progestin therapy. Patients who conceived after In the same year, Webb et al. reported one case of such con-
recovery from bleeding might have term deliveries. There ditions. This patient had previous tubal sterilization and pre-
was one case of full term pregnancy after TCRE at the vious dysmenorrhea which had been relieved with
Hysteroscopy Center of Fuxing Hospital, Capital Medical leuprorelin, who developed cyclic abdominal pain 6 months
University. A small infant was delivered by cesarean section. after endometrial ablation, followed by vaginal spotting.
Due to total implantation of placenta, the uterine corpus was Ultrasonography revealed an echo-free zone in uterine fun-
removed at the same time. So if pregnancy is detected during dus. She was treated by total hysterectomy and bilateral
the second or the third trimester of pregnancy and the patients oophorectomy, with hematosalpinx and dilation of proximal
have desire for delivery, continuation of pregnancy may be tubes identified at the time of operation, as well as endome-
considered. In order to achieve a better obstetric prognosis, a triosis detected in the right fallopian tube, which was con-
close and strict pregnancy care should be carried out to mon- sidered to be the cause of preoperative dysmenorrhea.
itor the fetal development and the placental function. For the However, postoperative pain was far serious than the preop-
patients who want a vaginal delivery, the third stage labor erative pain, leading to hysterectomy required. In 1999, Xia
should be handled properly; for the patients who want a reported four cases of PASS who underwent TCRE 1–8
cesarean section delivery, the possibility of hysterectomy years after tubal sterilization. Serious cyclic or persistent
should be considered. lower abdominal pain concomitant with hydrosalpinx devel-
oped within 3–11 months following TCRE. The features of
the cases are shown in Table 12.22. The first three cases had
12.8 Postablation-Tubal Sterilization no history of dysmenorrhea prior to TCRE and had a slight
Syndrome large uterus, and the fourth case had mild dysmenorrhea
with a normal uterus. Ultrasonography revealed uneven
Enlan Xia echo in the myometrium in the first case. At the time of
TCRE, adenomyosis, which was not suspected in all the
Postablation-tubal sterilization syndrome (PASS) is a late four cases, was confirmed in the first three cases by pathol-
complication of TCRE procedure. In 1993, Townsend et al. ogy and might be one of the causes of severe abdominal
first reported that 6 women who had a history of tubal ster- pain.
ilization followed by endometrial ablation suffered postop-
erative lower abdominal pain and dripping vaginal bleeding.
In all patients, hysteroscopy revealed obvious scarring of 12.8.1 Etiology of PASS
endometrium, and laparoscopy showed one or two tubal
swollen and hematocele in the proximal portion. As all the After TCRE, cyclic bleeding still occurs in the residual
patients have a history of tubal sterilization, it is named as functional endometrium or future regenerative endome-
postablation- tubal sterilization syndrome. In 1996, Bae trium in the uterine cavity. The uterine scarring or distor-
et al. reported on characteristic pathologic findings in six tion may block the discharge of menstrual blood, and if the
cases with postablation-tubal sterilization syndrome, which blockage occurs at the distal end of fallopian tubes, the
included hematosalpinx, and some changes under micro- upstream of menstrual blood leads to hematosalpinx, thus
scope such as endometriosis, acute and chronic inflamma- causing PASS.
Table 12.22 Characteristics of PASS in four cases

Postoperative
No. menstruation Onset of PASS Treatment Histological results
1 Amenorrhea for 3 Five months after Total hysterectomy, both oophorectomy, Adenomyosis, mild hyperplasia
months, followed by operation and appendix endometrium, bilateral chronic
spotting salpingitis, chronic appendicitis
2 Amenorrhea Five months after Total hysterectomy, left salpingectomy, Adenomyosis, endometrium at
operation right oophorectomy, and appendectomy proliferative stage; left chronic
salpingitis; chronic appendicitis
3 Amenorrhea for 3 Three months after Resection of intrauterine adhesion and Adenomyosis
months, followed by operation residual endometrium
spotting
4 Amenorrhea for 9 11 months after Exploration of the cavity and discharge of No
months, followed by operation hematocele
spotting
408 E. Xia et al.
12.8.2 Diagnosis of PASS hysterectomy. Townsend et al. suggested that laparoscopy

should be the first choice for treatment. Since the pathological
PASS may be one of the various causes of abdominal pain in changes of hematosalpinx might be bilateral, even if there
the late postoperative period, which usually occurs a few was only unilateral pain, the bilateral salpingectomy should
months after operation, and manifests as cyclic unilateral or be undergone. Among six cases of PASS, five responded well
bilateral abdominal pain. The pain may exacerbate due to the to laparoscopic salpingectomy or electrocauterization of the
tubal distention and may be combined or not combined with compromised fallopian tubes, and the last case underwent
vaginal spotting. The severity of pain is related to the length transvaginal removal of uterus due to the recurrence of the
of proximal fallopian tube, the area of residual endometrium, symptom. After treatment of six cases of postoperative cyclic
and the volume of hemorrhage. The late onset of symptoms pain, Bae et al. held that laparoscopic tubal resection assisted
may be explained by the slow endometrial regeneration. with selective hysterectomy could successfully relieve the
Ultrasonography may reveal an echolucent area in the uter- symptoms. Webb et al. believed that when there was an exten-
ine fundus. Diagnosis can be determined by tubal dilation sive understanding of this syndrome, a more conservative
detected via ultrasonography, laparotomy, or laparoscopy method than transvaginal resection of total uterus and bi-
(Fig. 12.22). adnexa might be taken, including laparoscopic salpingectomy
or hysteroscopic repeat resection of the residual endome-
trium. Among four cases treated by Xia, the first case achieved
12.8.3 Treatment of PASS no improvements after undergoing the exploration of the uter-
ine cavity twice and consistently applying nemestran and
PASS is a late complication of fallopian tubal ligation and danazol after eliminating the hematometra. Laparotomy was
endometrial ablation. So the earlier detection and manage- performed 15 months after operation and the resected speci-
ment are undertaken, the better the outcomes are. Gannon men revealed hematometra in two small cavities in the left
thought that the patients who underwent endometrial ablation uterine cornu and uterine fundus with bits of endometrium
after tubal sterilization should conduct ultrasonography and hematometra in the left fallopian tube. The second case
examination 4 months after operation for timely detection developed cyclic spasmodic pain in the lower abdomen as of
and elimination of uterine hematocele or resection of residual 5 months after surgery, which comes and goes, mild or seri-
endometrium, and if ineffective, the patients should undergo ous, with intramuscular injection of pethidine hydrochloride
(dolantin) ineffective in severe cases. Laparotomy was per-
formed 23 months after surgery and the resected specimen
revealed that the majority of the uterine cavity was occluded
due to adhesions and there was hematometra in three small
cavities in the left uterine cornu and swelling and hematome-
tra in the left fallopian tube. The third case developed sharp
pain in the left lower quadrant of abdomen during menstrual
period since the return of menses. The diagnostic hystero-
scope was inserted and gained access only 4 cm into the uter-
ine cavity due to occlusion of the upper segment of uterine
cavity. The operative hysteroscopy was applied to incise the
adhesive band and the uterine cavity was unblocked with a
whole length of uterine cavity 7.8 cm. The right tubal opening
and some hematometra were visible, while the left tubal
opening was not clear, and left lower abdominal pain disap-
peared. The fourth case developed cyclic sharp pain in the
lower abdomen 3 months after the return of menses and then
was concomitant with amenorrhea for 40 days with enlarged
uterus. Ultrasonography revealed bilateral hydrosalpinx and
hydrohystera. The uterine cavity was investigated under ultra-
sonography guidance, with resistance encountered at 4 cm of
insertion. A slight force forward brought a sense of break-
through and lead to the outflow of old and fresh blood about
200 mL. Then the acoustic image of dilated bilateral fallopian
Fig. 12.22 Uterine cavity and hematosalpinx with PASS under tubes disappeared, and abdominal pain was relieved
ultrasonography immediately.
12.8.4 Prevention of PASS careful resection of all sites of endometrium at the time of
operation, including the uterine cornua. The uterine cornua
In order to avoid perforation of uterus, there may be insuffi- may be deeply concaved in some cases, so its removal may
cient resection of the endometrium at the easily perforated be neglected, and if the patient had a history of previous
sites like the uterine fundus and uterine cornua at the time of tubal sterilization, PASS will occur.
TCRE, leading to the presence of active endometrium in this
area continuously. Its cyclic bleeding is obstructed in the
remaining parts of uterine cavity by the surgical scar and 12.9 Accidental Electrical Injuries
synechia and enters the obliterated fallopian tubes via the
tubal orifices, leading to the dilation of proximal fallopian Baoliang Lin
tubes, resulting in pain. The severity of the symptom may
depend on the length of proximal tubes, the extent of func- In recent years, great improvements on high-frequency electric
tional endometrium, and the volume of hemorrhage. devices have been made not only in quality but also in safety,
Therefore, the operator should remove the endometrium at and there is a significant decrease in accidental electrical inju-
the uterine cornua and uterine fundus as completely as pos- ries. However there is still risk of the occurrence of accidental
sible, and if not sure, electrocautery may be used, which is electrical injuries in the hospitals using the old type of high-
relatively safer than electroresection. The data presented by frequency devices. Therefore, the doctors and nurses who
Gannon et al. suggested that the incidence of PASS after roll- manipulate high-frequency electric devices must understand
erball endometrial ablation was far less than that of TCRE the accidents that may be caused by high-frequency waves.
(P < 0.007). Bae et al. proposed that when electroresection
and laparoscopic sterilization were performed at the same
time, laparoscopic electrocoagulation of the proximal fallo- 12.9.1 Electrical Burn Accidents
pian tube and destruction of uterine cornua should be per-
formed so as to prevent this syndrome. Electrical burn accidents are mainly caused by high intensity
Other authors have reported on the similar clinical mani- of high-frequency wave current, which can be divided into
festations. Magos et al. made a retrospective study that, in two types as follows.
234 patients after TCRE, 16 cases had hysterectomy for a
variety of reasons, including two cases undergoing hysterec- 12.9.1.1 Burns Around the Negative Plate
tomy at the ninth and 12th months after surgery due to severe Generally, in order to avoid a very high local current density,
abdominal pain. Of them, one case had hematometra at the a large negative plate is required for use. This negative plate
left cornu which was similar to that of PASS and had recur- needs to be connected to the human body comprehensively
rence following hysteroscopic drainage. Sorensen et al. and intensively and a close connection with the muscles rich
reported on one case who had hematosalpinx and dilated fal- in bloodstream can ensure a return current of high-frequency
lopian tube after EA which was similar to that of PASS, and wave; otherwise, electrical burns will occur. In addition, the
worsening cyclic abdominal pain within 8 months after sur- closer the connection of the negative plate to the surgical
gery. However, these two authors did not indicate whether site, the shorter is the running distance for the high-frequency
those patients had histories of tubal sterilization or not. wave in the human body.
Nowadays, with the wide application of TCRE, an increase
in the number of procedures and the prolonged duration of 1. Negative plate: Being easily bent, a negative plate can be
follow-up sheds light on the late complications of postopera- fixed at the bending positions like the thigh. However, if
tive abdominal pain. Steffensen and Schuster presented the negative plate of lead is bent several times, its surface
explanations of its causes as following: (1) intrauterine adhe- will become uneven, which will lead to a decrease in the
sions; (2) the regeneration of the residual endometrium at the contact area with the human body. In addition, due to
uterine fundus leads to hematometra; (3) the covering of the metal fatigue, the negative plate may crack or break, lead-
basal layer of endometrium by scar leads to iatrogenic ade- ing to a decrease in the effective area of the negative plate,
nomyosis and progressive dysmenorrhea; (4) the functional and high intensity of return current of the high-frequency
endometrium is squeezed into the myometrium under the wave current may result in electrical burn.
intrauterine pressure at the time of operation, leading to ade- 2. Negative plate for younger children: due to the small
nomyosis; (5) the endometrium at the uterine cornua is not area, it is easy to cause burns.
completely destroyed. Therefore, whether PASS is one inde- 3. Stainless steel negative plate: It is more commonly used
pendent syndrome requires further discussions. Wortman because it has advantages of no corrosion and easy clean-
held that the prevention of this syndrome was similar to the ing after use. In order to increase the electrical conductiv-
prevention of uterine hematometra after TCRE/EA, that is, ity, it is often wrapped with saline-soaked gauze when in
410 E. Xia et al.
use. If it is wrapped with dry gauze, or soaked with com- tronic instrument. A more serious consequence is the inter-
mon water instead of saline, there will be a decrease in ference with the artificial pacemaker which can endanger
the electric conductivity. Once the return current is inten- life.
sified at one site, it is easy to cause local burns. The stain-
less steel negative plate is hard in texture, if connected to
the protruding positions like the sacrum, scapula, and so 12.9.4 Accidents Caused by Sparks
on, the contact area will be reduced. If the patient’s posi-
tion changes, the negative plate migrates, there will also As flammable anesthetic gas is no longer used, explosive
be a decrease in the contact area, thus causing burns. accidents would not now occur, but under the conditions of
4. The electrolyte-free disinfectant liquid may flow in high concentration oxygen, the use of electric knife could
between the well-connected negative plate, and there will also be dangerous.
be a decrease in the contact area between the negative
plate and the human body, resulting in burns.
5. The disinfectant liquid may flow in between the well- 12.10 Other Complications
connected negative plate, which corrodes the negative
plate, resulting in a decrease in the contact area, thus Enlan Xia
causing burns.
12.9.1.2 Burns Outside the Site of Negative

Plate 12.10.1 Hematometra
High-frequency wave is very likely to stray, and burns occur
when the stray current passes through the site outside the Hematometra is a rare complication following TCRE and
negative plate. More common causes are: the negative plate EA. Uterine fundus and bilateral uterine walls are with folds,
being abnormal, the patient touching the metal parts of the which are easy to develop synechiae after operation, resulting
operating table, the stray current being caused by blood and in a small or narrow uterus. The anterior and posterior uterine
saline on the operating table, and stray currents being inducedwalls adhere to each other when uterine contraction occurs, if
by resectoscope via speculum. In addition, stray currents are such condition lasts long, synechia may occur. Most of such
also generated by electrode via the ECG and electroencepha- uterine synechia are asymptomatic, and abdominal pain is the
lography (EEG). Vilos et al. reported 13 cases of genital tractmajor symptom which prompts the patient to go to see a doc-
electrical burns due to the stray currents generated by specu- tor. The uterine synechia in some patients is detected when
lum of resectoscope. hysteroscopy is performed for other indications, so its inci-
dence is unknown. The lower segment of uterine cavity is
occluded due to synechiae, and when there is active endome-
12.9.2 Electric Shock Accidents trium in the upper segment still responsive to ovarian hor-
mone, the menstrual blood accumulates, leading to
Electric shock accidents are caused by electricity leakage. hematometra. Regular postoperative exploration of uterine
There are two types of electric shock: macro- and micro- cavity and (or) diagnostic hysteroscopy may prevent or detect
shock. Macro-shock occurs when electric current runs from the occurrence of this disease. Theoretically, the cervical ste-
outside through the skin or human body and runs out of the nosis at isthmus can cause hematometra, so Hamou proposed
body, micro-shock involves the running of an electric current that partial endometrial ablation should be performed and the
through the body tissues into the heart. Both types of shock endometrium of 1 cm at lower end of uterine cavity should be
may endanger life. retained. In fact, even after resection of the mucous mem-
brane at the upper segment of cervix, cervical stenosis and
secondary hematometra are also extremely rare. On the con-
12.9.3 Accidents Caused by Electromagnetic trary, all hematometra occurs in the uterine fundus, as long as
Interference there is still active endometrium in the fibrotic uterine cavity
after endometrial ablation, there is equal chance of occur-
High-frequency electric device is one that can generate high- rence of hematometra after total or partial resection of the
power high-frequency wave. When high-frequency electric endometrium. This condition occurs 2–16 months after oper-
device is in use, its powerful electromagnetic wave can affect ation and the reported incidence is 1.8% according to some
a variety of electronic instruments, such as ECG, EEG, com- scholars. Tapper and Heinonen reported that in 84 cases of
puter, and artificial pacemakers, and cause disorders induced TCRE, there were four cases of postoperative hematometra
by random wave to interfere with normal function of elec- occurring in first few days after TCRE. Postoperative treat-
ment with HRT following TCRE might also cause hemato- without menstruation, which may occur in a small number of
metra, whose symptoms are cyclic or persistent abdominal women. There is a postoperative decrease in menstrual blood
pain and intermittent vaginal bleeding. A uterine probe could and an increase in abdominal pain in some patients but the
not get to the uterus, but under ultrasonography hematocele in reasons remain unknown. Laparoscopic examination may
the uterus is visible, which is easy to diagnose. If exploration reveal endometriosis and other causes of pelvic pains.
of uterine cavity, elimination of hematocele, and maintaining However, there is still a lack of evidence for extrinsic endo-
a smooth drainage of uterine cavity produce good treatment metriosis caused by hysteroscopic operations, and it is most
effects, hysteroscopic resection of intrauterine adhesions and likely to cause internal endometriotic foci and the small ecto-
residual endometrium under ultrasonography intervention pic foci buried in the myometrium. This condition is similar
can prevent its recurrence. Romer et al. reported that one case to intrauterine adhesions with abdominal pain described by
experienced cyclical abdominal pain 13 months after TCRE Asherman, and 25% of the patients with Asherman’s intra-
and hematometra occurred due to obliteration of the cervical uterine adhesions have pelvic pain. In respect to treatment,
internal ostium. They pointed out that all patients should have only analgesics are ineffective to relieve the severe abdomi-
a regular clinical and sonographical follow-up after opera- nal pain, and there is no report about the effect of laparo-
tion. But it still remains to be confirmed whether it is neces- scopic presacral neurectomy, so its efficacy is unclear, some
sary to perform regular exploration of uterine cavity within patients require hysterectomy. Mints et al. reported that in 97
weeks after operation so as to reduce its occurrence, while it cases who were followed with a mean period of 29 months,
may cause infection and perforation of the uterus. The incom- 11 women (11%) suffered from postoperative dysmenorrhea.
plete drainage of uterine cavity after operation may also cause The following theories can explain the abdominal pain after
hematometra and spasmodic pain in the lower quadrant of TCRE: (1) Intrauterine adhesions; (2) The regeneration of
abdomen. Among 149 cases of TCRE performed by Lin, reg- residual endometrium at the uterine fundus leads to hemato-
ular outpatient treatment by dilation of the cervix was admin- metra; (3) The covering of the basal layer of endometrium by
istered all within 1 month after operation and there was no scar leads to iatrogenic adenomyosis and progressive dys-
occurrence of hematometra. Among 1100 TCRM procedures, menorrhea; (4) The active endometrium is squeezed into the
one case developed cervical adhesion and hematometra due myometrium under the increased intrauterine pressure at the
to the resection of myoma near the cervix and cured after time of operation, leading to adenomyosis; (5) The endome-
cervical dilation and elimination of hematocele. Hill et al. trium at the uterine cornua is not completely destroyed.
reported on 24 cases of hematometra who received treatment Steffensen and Hahn held that resection of a submucous
by puncture, drainage, flushing with irrigation fluid via hys- adenomyoma during TCRE increased the risk of distention
teroscopy, of which one case was treated by vaginal hysterec- fluid absorption. Later cyclic pelvic pain after operation was
tomy. He pointed out that any patient who underwent TCRE associated with large amount of intraoperative fluid absorp-
and EA should be informed of the potential complications. tion and postoperatively persistent menstrual bleeding.
McCausland et al. reported partial endometrial ablation could
successfully treat menorrhagia in patients without deep ade-
nomyosis, and it did not cause intrauterine adhesions and 12.10.3 Iatrogenic Uterine Adenomyosis
hematometra. In 2002, McCausland et al. undertook a study
of the frequency, diagnosis, treatment, and prevention of As there are more and more surgical cases, scholars have
symptomatic cornual hematometra and PASS in 50 patients come to realize the presence of adenomyosis confirmed by
who received total rollerball endometrial ablation. After a subsequent hysterectomy that might cause the postoperative
follow-up of 4–90 months, 5 (10%) were diagnosed by ultra- abdominal pain which is hard to explain. In UK, a large scale
sonography or MRI, with two patients with cornual hemato- of cross-sectional study was undertaken in thirteen hospitals
metra and 3 patients with PASS. Subsequent GnRH-a or of Scottish Health Board to assess the satisfaction in 978
hysteroscopic drainage achieved limited effect, and hysterec- cases at 12 months postoperatively by questionnaire between
tomy with salpingectomy was performed in recurrent cases. December 1991 and December 1993 who had hysteroscopic
They suggested that the incidence of hematometra was not surgery for menstrual disorder. The criterion for satisfaction
uncommon (10%) and could be decreased by partial EA. was that there was postoperative menstrual improvement and
no need for any form of treatment. Eighty-four percent of
those returning their questionnaires were satisfied or very
12.10.2 Abdominal Pain satisfied. The main reason for dissatisfaction was exacerba-
tion of pain. There was no constant relationship between the
Severe lower abdominal pain is the condition related to the satisfaction rate and postoperative amenorrhea rate.
occurrence of hematometra, which is often cyclical, but there Adenomyosis was hard to determine except for triple symp-
is pain without hematocele in the uterine cavity and even tom complex prior to operation. Bae et al. held that it still
412 E. Xia et al.
remained to be explored whether the postoperative exacerba- by most operators, the improvement of menstruation is
tion of abdominal pain was caused by worsening of previous achieved in 80–90% of patients after one surgery, and the
adenomyosis or by surgery. Some scholars thought that post- recurrence of symptoms after a successful electroresection
operative adenomyosis should have developed before TCRE or laser surgery is extremely rare. Although it is a novel pro-
or EA and had no relation with the surgery. Mints et al. cedure and the follow-up data are limited, the majority of
reported that 29% of cases suffered from adenomyosis after women benefit from this surgery, and there are still excep-
operation. Data reported proved that adenomyosis was easier tional patients who have amenorrhea after total resection of
to occur when electric cutting loop was applied in TCRE endometrium but heavy bleeding occurs suddenly 2 years
than that when rollerball or laser in EA was applied. The later. If initial treatment fails and the symptom recurs, a sec-
reason might be that endometrium is more easily retained in ond operation may be performed. Hysterectomy should be
TCRE than in EA and is covered by scarring tissues subse- reserved as a last resort, and this novel procedure should not
quently, leading to iatrogenic endometriosis. Another reason be performed by force against the patient’s wishes. The inci-
might be that at the time of endometrial resection, the endo- dence of postoperative abnormal uterine bleeding is 5–10%,
metrium enters through the traumatized vessels or muscle which occurs more often when there is endometrial regener-
layers into the uterine myometrium, causing this disorder. ation. However, there is such case on earth who has bleeding
Keckstein reported that adenomyosis was a disease of the but without endometrium confirmed by hysteroscopy or hys-
myometrium, which could be diagnosed by hysteroscopy. terectomy, which was thought to be induced by uterine vas-
The depth of the adenomyosis might be investigated by tran- cular dysplasia according to the father of
scervical punch biopsies or loop resection. Superficial ade- hysteroscopy—Hamou from France. Such kind of hemor-
nomyosis could be managed by transcervical coagulation or rhage is always sudden and transient, and sometimes may
resection of endometrium, which could lead to iatrogenic heal spontaneously. There has been no good way in its pre-
adenomyosis. However, it could be treated by second-look vention and treatment up to now.
hysteroscopy. Adenomyosis might also be caused by partial
EA or TCRE. In selected cases, it was possible for hystero-
scopic treatment of symptomatic focal adenomyosis. Some 12.10.5 Malignant Lesions of the Uterus
scholars have noticed that the purple blue dots were visible
in the superficial myometrium in patients who had hysterec- There are two types of malignant lesions to be discussed,
tomy following TCRE, which was ectopic endometrium. namely the latent endometrial carcinoma and the long-term
There are two kinds of explanation for it. At the beginning of risk of canceration. Electroresection can provide tissues for
advocating hysteroscopic resection, it was discovered when histological examination, which is superior to other proce-
patients asked treatment for abdominal pain. So, it was dures in this respect. It still is a purely theoretical issue
thought that when the endometrium was compressed into the whether subsequent canceration occurs in buried endome-
myometrial wall during operation, if survived, adenomyosis trial island, or whether endometrial cancer is concealed by
occurred, which was a complication of TCRE. However, due intrauterine adhesion or cervical stenosis. However, it is
to an increase in the number of cases, pathological findings most important that the ablation of the endometrium reduces
showed that adenomyosis foci were found in 8% of the the risk of endometrial canceration. If there are still bits of
resected muscle strips in which adenomyosis was not preop- tissues of endometrium in situ at the end of the operation, the
eratively diagnosed. Recently, doctors had been trying deep chances of development of endometrial cancer are slim.
cutting in transcervical resection of the endometrium, which There is no change in the probability of occurrence of uterine
reached 4–5 mm underlying the endometrium, and the detec- sarcoma, cervical cancer, and ovarian tumor. In the
tion rate of adenomyosis had been increased up to 46%. So, Hysteroscopy Center of Fuxing Hospital, Capital Medical
it was thought that there were more patients with adenomyo- University, there has been a case of endometrial cancer
sis prior to operation, but we could not explain why they developed 8 years after hysteroscopic electroresection. This
were preoperatively asymptomatic while abdominal pain 60-year-old woman underwent TCRP and TCRE for meno-
occurred postoperatively. pausal bleeding and endometrial polyps, with the pathologi-
cal examination of excised tissues showing endometrium
and endometrial polyps. At the postoperative follow-up,
12.10.4 Treatment Failure and Recurrence there was no bleeding and fluid discharge all the time until
of Symptoms vaginal spotting occurred 8 years later. Hysteroscopic exam-
ination and biopsy were performed 3 days later and revealed
In the short-term after operation, clinically, there should be thickened endometrium with the length of uterine cavity
clear distinctions in treatment failure, lack of improvement 7 cm. Histological findings showed atypical endometrial
of symptom, and recurrence of symptom. In cases performed hyperplasia and suspicion of cancer. Extensive removal of
total uterus and both adnexa was performed and no enlarged 12.10.10 Death
lymph nodes in pelvic cavity were detected. Postoperative
histological examination revealed diffuse well-differentiated The greatest risk of TCRE does not lie in the operation, but
endometrial adenocarcinoma, which invaded 1/2 of myome- in the operator. There are two reports about 27 cases who
trial layer and involved bilateral cornua, and no abnormali- died of severe hyponatremia induced by body fluid overload
ties were found in bilateral ovaries and fallopian tubes. At and died due to the fatal intraabdominal bleeding caused by
present, there are eight cases of occurrence of endometrial uterine perforation. Among them, the common feature is that
cancer after TCRE reported worldwide, and all cases had the operators are inexperienced and lack either the basic
preoperative conditions of endometrial simple or complex knowledge or the basic skills, so hysteroscopic surgery is not
hyperplasia. So, to these patients, postoperative treatment suitable for the beginners. In Scotland, it was reported that
with high progesterone should be administered. among 978 cases having hysteroscopic surgery, there was
one death from toxic shock syndrome. Hulka et al. concluded
that among 17,298 hysteroscopies, there were three deaths.
12.10.6 Uterine Necrosis Bae et al. pointed out that when the uterine cavity was dilated
to 10–11 mm using laminaria and the intrauterine pressure
Rousseau et al. reported on one case with uterine myometrial was maintained constantly below 70–75 mmHg, there would
coagulative necrosis occurring after Nd-YAG laser endome- be a better uterine distention and vision field and might
trial ablation. This patient had initial adenomyosis and was reduce the occurrence rate of the major potential complica-
treated preoperatively with Luteinizing Hormone-Releasing tions like perforation of the uterus. The prerequisite to avoid
Hormone (LH-RH). death is the confident diagnostic techniques in using hyster-
oscopy. On the contrary, an operator who is expert in lapa-
roscopy cannot replace the one expert in hysteroscopy in that
12.10.7 Pulmonary Hemorrhage these two kinds of procedures are so different from each
other. TCRE and other endometrial ablation procedures are
In 2007, Su et al. reported for the first time a rare fatal com- considered as “minimally invasive,” but in the hands of a
plication of lung collapse resulted from pulmonary hemor- wrong operator, it will become “the greatest trauma.”
rhage after hysteroscopic operation.
12.10.11 Complications of the Second

12.10.8 Transient Blindness Generation Endometrial Ablation
It is known to urologists that transient blindness may be The second generation endometrial ablation is performed
induced after transurethral resection of the prostate with with a disposable device which is inserted into the uterine
1.5% glycine as the irrigating fluid, which was first reported cavity to ablate, lyse, or destroy the endometrium, so it is
by Israeli Dr. Levin and Ben-David in 1996. In 1999, Indian also called global endometrial ablation. In contrast to first
Dr. Motashaw and Dave reported a case of postoperative generation endometrial ablation, the global endometrial
transient blindness in a 38-year-old woman who underwent ablation does not require uterine distention and uses heat
TCRM and TCRE with 1.5% glycine as distention medium. instead of electricity. Its device is computer-controlled,
In 2003, Turkish Karci and Erkin also reported one case of which can display pressure, temperature, and time. So it is
transient blindness occurring after TCRM. relatively safe in general, but there are also complications. In
2003, Gurtcheff and Sharp reported about the complications
of global endometrial ablation present in Medline and refer-
12.10.9 Nerve Injury ences, which included hemorrhage (two cases), pelvic infec-
tion (one case), endometriosis (20 cases), skin burns (two
Nerve injury is often caused by fibular nerve compression or cases of grade 1), hematometra (nine cases), vaginitis and(or)
overstretching of the sciatic nerve with its occurrence rate of cystitis (16 cases). Data from the Food and Drug
0.01–0.04%. Most of the nerve injuries are caused by incor- Administration and User Facility Device Experience
rect lithotomy position during hysteroscopic surgery or long- (MAUDE) showed that there were 85 complications in 62
time compression from the leg holders and equipment. Its patients, which included bowel thermal injuries in eight
symptoms include pain or paralysis, which can recover com- cases, uterine perforation in 30 cases, of which 12 cases
pletely, but sometimes takes longer time. To avoid this trou- required immediate laparotomy, three cases were transferred
ble, the operator should check in person the patient’s into ICU, one case developed necrotizing fasciitis leading to
positioning and body posture before operation. genital mutilation, ureteral stoma, and bilateral below-knee
414 E. Xia et al.
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Hysteroscopy for Other Purposes
13
13.1 Vaginoscopy 13.1.1 Indications of Vaginoscopic Diagnosis

and Operation
Vaginoscopy is also named non-touch hysteroscopy, which
applies hysteroscopic instruments and non-invasive tech- Vaginal diagnosis and operation may be conducted in young
niques (such as no placement of speculum, no holding of girls, unmarried women, or postmenopausal old women who
cervix, no dilation of cervical canal, no probe of the length of experience vaginal bleeding or abnormal discharge. Diseases
uterus, distension of the cavity with low pressure, and use of which can be discovered and managed by vaginoscopy
mini instruments) to accomplish the hysteroscopic examina- include:
tion so as to reduce the pain and discomfort which are caused
by traditional hysteroscopy such as placing the speculum and 1. Discovering and removing vaginal foreign bodies. In the
cervical forceps, using the scope with large diameter, and Hysteroscopy Center of Fuxing Hospital, Capital Medical
requiring local or general anesthesia. With the extensive use University, vaginal foreign bodies such as small glass
of office hysteroscopy, vaginoscopy has been gradually balls, condoms, nut shells, pen caps, buttons, sands, cot-
favored by both doctors and patients. The application of it ton, small bottle caps, spring rings, plastic toy fragments,
cannot only replace the traditional hysteroscopy, but also sausage wrapping buttons, small metal rings, etc. have
favor the female infants, young girls, and unmarried women been detected and removed.
of child-bearing age because of no damage to the hymen. 2. Discovering vaginal infection and treating by vaginal
Vaginoscopic examination and operation are conducted irrigation.
by inserting a diagnostic, therapeutic, or operative hystero- 3. Discovering benign lesions including vaginal mucosal
scope into vagina under the condition without placement of adhesions, vaginal granulation, vaginal polyps or cervical
speculum, irrigating and dilating the vagina with normal polyps, etc., and treating by vaginal operations.
saline, clearly visualizing the vaginal wall and cervix, and 4. Discovering, sampling, and diagnosing vaginal or cervi-
then entering the uterine cavity via cervical canal, and cal neoplasms, and following up postoperative outcomes.
inspecting and treating vaginal, cervical, and uterine abnor- In our Hysteroscopy Center, endodermal sinus tumor,
malities. During the procedure of vaginoscopy, it does not rhabdomyosarcoma, hemangioma, botryoid sarcoma,
place the speculum, not dilate the cervix, and not probe the Mullerian papilloma, etc. in young girls have been
length of uterine cavity, and it can preserve the integrity of diagnosed.
the hymen for young girls or unmarried women, so it can 5. Vaginoscopy can be placed into uterine cavity, and dis-
greatly reduce the injuries and pain caused by speculum to cover, diagnose and treat intrauterine lesions.
young girls, unmarried women, and postmenopausal women.
Therefore, it has been a commonly used diagnostic and oper-
ative method for those patients in recent years. 13.1.2 Contraindications of Vaginoscopic
Diagnosis and Operation
1. Acute or subacute genital tract infection.

2. Severe adhesions in vagina.
J. Zheng (*) · E. Xia

Beijing, China

422 J. Zheng and E. Xia
13.1.3 Procedures of Vaginoscopic Diagnosis sand, bottle caps, string rings, etc. which lie in the fornix,
and Operation middle segment, or external os of vagina (Fig. 13.2a–d).
Because of long-term detention of vaginal foreign bodies,
13.1.3.1 Vaginoscopic Examination the vaginal wall where the foreign body locates com-
Vaginoscopic examination applies diagnostic hysteroscope monly present inflammatory changes. The vaginal for-
with the diameter of the outer sheath being 3.1 mm, 4.5 mm, eign bodies can be removed with hysteroscopic foreign
or 5.5 mm. 0.9% normal saline is used as media for dilating forceps under the direct vision of the hysteroscope.
the vagina, with the distention pressure set at 60–80 mmHg. 2. Vaginitis in children: Vaginoscopy in female children
Vaginoscopic operations can use 6.5 mm therapeutic hys- sometimes can visualize purulent secretion in vagina, yel-
teroscope, 8 mm or 9 mm monopolar hysteroscopic resecto- low membranous tissues which cover the vaginal wall,
scope, or 8.5 mm bipolar hysteroscopic resectoscope. congestive, punctate hemorrhage, erosion, and granula-
tion proliferation on vaginal mucosa, and even inflamma-
13.1.3.2 Vaginoscopic Diagnosis and Operation tory polyps (Fig. 13.3). Repeated onset of vaginitis may
A diagnostic hysteroscope is introduced into the vagina via the also lead to adhesions of vaginal mucosa (Fig. 13.4).
hymen, and proceed slowly from the vaginal external os to Vaginitis can be treated by regular vaginal irrigation with
cervix under direct vision. Then vaginal walls, vaginal fornix, normal saline, 0.05% iodophor or antibiotics. Histological
and ectocervix were inspected in sequence (Fig. 13.1a, b). examination of sampling biopsy may indicate inflamma-
After examining the vagina and cervix, the hysteroscope goes tory tissues, and even inflammatory polyps.
upwards from vaginal posterior fornix over the posterior lip of 3. Vaginal and cervical neoplasm: Vaginoscopy for neo-
the cervix into cervical os, and observing the cervical canal. plasm may discover vaginal or cervical space-occupying
Then it goes through the cervical canal to the internal os and lesions, which can be polyps, granulation proliferation,
progressively inspects the whole cavity. The hysteroscope is focal proliferation, cervical or vaginal tumors (Figs. 13.5,
then retrieved slowly and detects the whole vagina again under 13.6 and 13.7). Sampling of the neoplasm can be obtained
its expansion. Based on the results of vaginoscopy, vaginal by hysteroscopic biopsy forceps and be sent for histologi-
irrigation and target biopsy may be conducted. Abnormal con- cal examination, or the neoplasm can be completely
ditions which may be discovered by vaginoscopy include: excised for histological examination. Alternatively a loop
electrode of hysteroscopic resectoscope is used for resec-
1. Vaginal foreign bodies: Vaginoscopy may detect vaginal tion and the resected tissues are sent for histological
foreign bodies such as hair, button, cotton, pen caps, examination.
a b
Fig. 13.1 (a) Whole picture of vagina with vaginoscopy. (b) Normal cervix with vaginoscopy
13 Hysteroscopy for Other Purposes 423
a b
c d
Fig. 13.2 Vaginal foreign bodies in young girls. (a) Cotton. (b) Pen cap with rubber and metal sheath. (c) Curvy metal ring. (d) Plastic ball
13.1.3.3 Vaginoscopic Removal of Vaginal scope (Fig. 13.8a, b). After the removal of the foreign bodies,
Foreign Bodies vaginal walls should be inspected to determine condition of
Vaginal foreign bodies can be removed by grasping with for- traumatic surface, and whether there are bleeding and fistula
eign forceps which is introduced through hysteroscopic formation or not. If there is bleeding, rollerball electrode can
working channel or is inserted beside the hysteroscope. Or a be used to coagulate for hemostasis. And vaginal irrigation
surgical forceps is introduced into vagina, and grasps and should be determined according to the condition of vaginal
removes the foreign bodies under the direct vision of vagino- inflammation.
Fig. 13.5 Vaginoscopy reveals vaginal polyps with 2 cm in diameter

Fig. 13.3 Vaginal mucosal congestion with punctate hemorrhage visu-
alized with vaginoscopy
Fig. 13.6 Vaginoscopy for vaginal foreign body. An inflammatory

polyp with 1 cm in diameter is detected at left wall of vaginal lower
Fig. 13.4 The inflammation occurs repeatedly after the removal of segment
vaginal foreign bodies. Vaginoscopy reveals adhesions between cervi-
cal posterior lip and vaginal posterior fornix
a b
Fig. 13.7 (a) Vaginoscopy for hemangioma. A space-occupying lesion irregular clustery hyperplastic tissue with a fragile surface and thick-
is detected with plenty of spotty vessels on its surface which appears as ened vessels is detected at left-posterior vaginal wall
a strawberry-like change. (b) Vaginoscopy for Mullerian papilloma. An
a b
Fig. 13.8 (a) Hysteroscopic foreign forceps is grasping the vaginal foreign body. (b) A surgical forceps is introduced into the vagina to grasp the
foreign body—a pink plastic ball
13.1.3.4 Vaginal Wall Biopsy Under good effects. In 2010, Cooper et al. reviewed many good,
Vaginoscopy relevant articles and discovered that when compared with
A hysteroscopic biopsy forceps can be inserted through traditional hysteroscopy, vaginoscopy could significantly
working channel of the hysteroscope, or be parallelly inserted reduce the pain and should be considered as a standard
beside the hysteroscope, and grasps the vaginal wall or vagi- method of office hysteroscopy. In 2012, Zheng et al. from the
nal/cervical neoplasm, with a small amount of tissues Hysteroscopy Center of Fuxing Hospital, Capital Medical
removed and sent for histological examination (Fig. 13.9a, University reported that 140 patients (15 young girls, 20
b). unmarried women, and 55 other women) underwent vaginal
and intrauterine examination and operation with the tech-
13.1.3.5 Hysteroscopic Resection or nique of vaginoscopy. It was found that vaginoscopy could
Coagulation Vaginoscopically significantly reduce the pain caused by hysteroscopic proce-
Vaginal or cervical neoplasms can be excised by hystero- dures, avoid the damage to the hymen, and discover the
scopic resectoscope. The resected tissues should be sent for bleeding caused by vaginal disorders. In addition, the hys-
histological examination. The resecting technique is the teroscope was more flexible for movement, which was in
same as that of hysteroscopic resection (Fig. 13.10a, b). favor of the patient whose uterus was extremely flexed. They
During the operation, active bleeding on cutting surface may held that vaginoscopy had less trauma than routine hysteros-
be stopped by coagulation with hysteroscopic rollerball elec- copy and was especially suitable for investigation in young
trode (Fig. 13.11). Adhesions in vagina can be divided with girls and unmarried women with low genital tract disorders,
hysteroscopic needle electrode (Fig. 13.12). so it had the value of popularization and application.
13.1.4 Applications of Vaginoscopic 13.2 Hysteroscopy in Place of Culdoscopy

Examination and Operation in Fertiloscopy
Early in 1997, Paschopoulos et al. reported that in 324 cases Laparoscopy is an effective means in the diagnosis of pelvic
of vaginoscopy, 211 procedures (65%) achieved success. factor infertility. Due to its seemingly great trauma to the
After this, more scholars applied this technique in female infertile women without obvious pelvic lesions, the scholars
infants, young girls, and unmarried women and achieved have begun to try transvaginal hydrolaparoscopy (THL) on
a b
Fig. 13.9 (a) Hysteroscopic biopsy forceps is grasping the vaginal anterior wall to get some tissues for histological examination. (b) Hysteroscopic
biopsy forceps is grasping the membranoid neoplasm to get some tissues for histological examination
a b
Fig. 13.10 (a, b) Vaginoscopically resection of vaginal lesions with a 7 mm hysteroscope and a closed-loop electrode
Fig. 13.11 Hysteroscopic rollerball electrode is coagulating the active

bleeding points on vaginal anterior wall
patients who had unexplained infertility with normal gyne- Fig. 13.12 Hysteroscopic needle electrode is dividing the adhesions
cological examination and TVS and without a history of pel- on right vaginal wall
vic disease or pelvic surgery. The results suggest that the
advantages of THL include repeatability of pelvic examina-
tion and safety, and 40% of the patients who have undergone diagnostic technique. Fertiloscopy is not fundamentally dif-
THL can avoid laparoscopy. Fertiloscopy, born in twenty- ferent from laparoscopy in diagnostic function. Due to its
first century, combines transvaginal hydrolaparoscopy (cul- simplicity, safety, and minimal invasiveness, it is considered
doscopy, lap and dye, and hysteroscopy), salpingoscopy, and to be a good alternative to diagnostic laparoscopy, and its
microsalpingoscopy, which forms a new minimally invasive application is becoming more and more popular.
The basic procedure of fertiloscopy is to introduce the stop endoscopic pelvic exploration in infertile women. Its
endoscope through the posterior vaginal fornix into the pel- standard procedure is not only harmless but also can detect
vic cavity as that of transvaginal hydrolaparoscopy, and to the posterior pelvic abnormalities in asymptomatic patients,
observe pelvic anatomy and tubal lesions in infertile women including lesions on uterine posterior wall, ovary, small
with saline as distention medium. The development of this intestine, and rectum. Under general or local anesthesia, the
minimally invasive diagnostic method can be traced back to patients may have good tolerability, and it can be performed
culdoscope in the early twentieth century. In 1901, von Ott in an office setting.
was the first to inspect the pelvic cavity of a pregnant woman Indications for THL: (1) Early stage unexplained primary
through an incision in the posterior vaginal fornix via cysto- or secondary infertility, no obvious pelvic abnormalities by
scope by using a head mirror to reflect light. Thereafter, he gynecological and ultrasonography examination; (2) Infertile
became the first culdoscopist. In the next 40 years, there have women with HSG or ultrasonography findings indicating
been physicians or surgeons from Germany, Sweden, intrauterine abnormalities, which requires diagnostic hyster-
Switzerland, Denmark, South America, Britain, the United oscopy and (or) operative hysteroscopy; (3) Women who
States, Hungary, and other countries committed to the cannot conceive after at least 3 cycles of treatment but with a
exploration and development of laparoscopy. Just as laparo- normal HSG result; (4) Endoscopic follow-up after abdomi-
scopic techniques were developing rapidly, the outbreak of nal or laparoscopic myomectomy, tubal surgery, and grade
the Second World War restricted the international technical III or IV endometriosis surgery, with THL taking the place of
exchanges and cooperation. As of the early 1940s to the late HSG or standard second-look laparoscopy; (5) An alterna-
1960s, many medical centers used culdoscopy to replace tive to standard laparoscopy so that a simple laparoscopic
laparoscopy. Culdoscopy, which was introduced as a mini- diagnosis can be done for hysteroscopic surgery. THL can be
mally invasive procedure in 1944, became an alternative to considered as a first-line investigation method, and diagnos-
laparotomy for diagnosis and assessment of pelvic pain, tic laparoscopy will be as the second method.
infertility and pelvic mass. After the Second World War, Contraindications for THL: (1) Significant pelvic lesions
under the influence of Raoul Palmer and Hans Frangenheim, and lower genital tract infection; (2) Uterine retroversion and
the “father of modern operative laparoscopy,” laparoscopic fixation, closure of Douglas’ pouch; (3) Patients who have
technology began to boom again in Europe. As there were indications for laparoscopy should not try to undergo
some further development and improvements on the laparo- THL. Verhoeven and Brosens pointed out that posterior for-
scopic system and surgical instruments, diagnostic laparos- nix puncture may be unsuccessful in women with stenosed
copy has begun to mature since the 1970s. Due to wide field upper vagina and obesity, and the failure rate of the puncture
of vision, laparoscopy has become an effective means of in women with a retroverted but not fixed uterus is 50%,
endoscopic diagnosis while culdoscopy has fallen into obliv- which can be considered as relative contraindications. In
ion in history. A large number of diagnostic laparoscopies addition to diagnosis, THL can also be used for some simple
revealed no pelvic abnormalities in 49%–70% of patients. treatment, such as division of adhesions, ovarian drilling and
This phenomenon urged doctors to contemplate and seek a electrocoagulation of endometriotic foci, etc.
less traumatic pelvic examination procedure to replace the The maturity and wide application of IVF technology
standard laparoscopy. Not until late 1990s, the company provides options of surgery or IVF in the treatment of the
Circon developed a special Veress needle-cannula system, fallopian tubal diseases. The evaluation of the fallopian tubal
which makes THL possible. THL is a new culdoscopy. The lesions includes the condition of tubal mucosa and tuboperi-
difference between culdoscopy and THL is that when cul- toneal environment, so only HSG and laparoscopic diagnosis
doscopy is performed, the patient is in a knee-chest position are obviously inadequate. Therefore, this leads to the birth of
with air as distention medium, but the patient is placed in a fertiloscopy, which combines THL with salpingoscopy and
lithotomy position when THL is performed with peritoneal microsalpingoscopy.
distention by saline. The similarity between them lies in that In 1997, Watrelot et al. proposed the concept of fertilo-
both instruments are inserted into the pelvic cavity through scope, and defined it as the combination in one investigation
the rectouterine pouch. In 1998, Belgian Gordts et al. of transvaginal hydropelviscope, dye-test, optional salpingo-
reported on THL for the first time. But its application was far scope, and eventually hysteroscope, which can be performed
less common than that of laparoscopy and hysteroscopy, on an outpatient basis under local or block anesthesia. In
which might be related to its limited indications. At present, 1999, Watrelot published his experience with fertiloscope in
the application of HSG and laparoscopy to investigating the English, which was performed on 160 infertile patients with
causes of infertility is greatly controversial. THL may avoid unknown reason. Fertiloscope was successfully performed in
the real surgical operation like laparoscopy and HSG may 154 patients (96.2%) and failed in five because of technical
induce improper X-ray exposure. The combined application problem or adhesions in the pouch of Douglas. It was normal
of hysteroscopy and dye tubal patency can complete one- in 60 patients (37.5%) under fertiloscope. One patient
encountered rectal injury (0.6%) and was treated with antibi- tions. In 2001, Gordts et al. from Belgium made a retrospec-
otics for 2 days conservatively. Findings of fertiloscopy tive survey of four centers on complications of full-layer
included endometriosis in 21 patients (13.1%), inflammation bowel injury following THL and fertiloscopy. A total of 3667
in deep pelvic cavity in 58 cases (36.2%), tubo-ovarian adhe- procedures were included, among them 24 bowel injuries
sions in 27 cases (16.8%), and mini abnormalities in 15 cases (0.65%) occurred. The occurrence rate of bowel injury
(9.3%). For women with pelvic inflammatory lesions decreased to 0.25% when the initial period of application is
detected, salpingoscopy was performed, with 39% of cases excluded. All the injuries were recognized during surgery
undergoing partial examination due to external tubal adhe- and 22 cases were successfully treated without poor out-
sions but clearly visualizing the fimbriae. IVF procedures comes. In 2004, Chiesa-Montadou et al. reported on two
were undertaken directly in 74 patients (46.2%) so as to complications of ovarian drilling by fertiloscopy. Among 43
avoid a further laparoscopy. The case of rectal perforation women who underwent fertiloscopy, 15 women were treated
was the 26th among 160 cases, who suffered from severe by ovarian drilling during fertiloscopy because of PCOS
deep infiltrating endometriosis of the rectovaginal septum. with two complications occurring. The first case had a deli-
Thereafter, a Veress needle puncture injection was used, and cate operation with an ovarian incision only about 0.5 cm,
then the trocar was inserted, no rectal perforation occurred but was converted to laparoscopy due to heavy hemorrhage.
again. The insertion of salpingoscope in the procedure of fer- The second case underwent drilling procedure with small-
tiloscopy is much easier than that of laparoscope, and can bowel loops and ovaries intertwined, and suffered nausea,
obtain more information about mucosal adhesions in tubal vomiting, and radiating pain in left shoulder on the first day
fimbriae and ampullary. The main advantages of fertiloscopy after operation. Laparoscopic examination revealed intesti-
are safety and minimal invasiveness. Compared with lapa- nal perforation and laparotomy was performed immediately
roscopy, it will not damage the large blood vessels, not to resect the intestinal segment. They indicated that ovarian
require Trendelenburg position and not need CO2 pneumo- drilling for fertiloscopy is just a beginning, but these two
peritoneum, so there will be no acidosis induced by CO2, cases suggested no procedure is without adverse effects and
thus attracting attention of the academic field. In the next risks. So it was necessary to carry out further study with lon-
year, Messin from Italy reported his experience with fertilos- ger follow-up to properly access the effectiveness and risks
copy and held that fertiloscopy was a useful first-line alterna- of fertiloscopy.
tive procedure in diagnosing infertility. Fertiloscopy has the The recent studies have ascertained the role of fertilos-
advantage of strictly limiting the indications of culdoscopy copy. In 2007, Nohuz et al. made a retrospective study of
and maintaining a high diagnostic quality. Furthermore, it is 229 women with primary or secondary infertility without
cost-effective, economizes on manpower and decreases the pathology, with successful fertiloscopic examination proce-
surgical risks, and the patient has a better compliance. In dures in 203 women (88.6%). Fifty eight patients required a
2002, Watrelot et al. reported the results of fertiloscopy in laparoscopic intervention because of pelvic lesions revealed
500 infertile women with unknown reason, of whom 85% by fertiloscopy, which included pelvic adhesions, endome-
had salpingoscopy. Of those with no pathology detected by triosis, tubal disease, failure in visualizing the adnexa and
fertiloscopy, abnormalities were found in 8.2% with salpin- ovarian cysts. Complications occurred in 5 patients includ-
goscopy, and 37% with microsalpingoscopy. They held that ing two rectal injuries, two hemorrhages and a postoperative
intratubal exploration should be conducted when evaluating salpingitis. The authors held that fertiloscopy was safe and
the infertility. In 2004, Fernandez et al. from French devel- reliable, and can be considered as a substitute for laparos-
oped ovarian drilling by transvaginal fertiloscopy for the first copy when evaluating infertile women with unknown rea-
time. They conducted a prospective study to evaluate the out- son. In the same year, Watrelot from France pointed out that
comes of ovarian drilling with bipolar energy under fertilos- in the treatment of fallopian tubal diseases, the option of
copy in women who had PCOS and resisted to clomiphene tubal surgery or IVF was based on tubal lesions, which
citrate. During a mean follow-up of about 18 months, 73 included the conditions of both tubal mucosa and tuboperi-
women (91%) got recovery of ovulatory menstruation, and toneal environment. Endoscopic examination could accom-
44 women got pregnancy with the mean time to conceive plish their assessment, but fertiloscopy could take its place
4 months. Delayed miscarriages occurred in 8 women, and due to its minimal invasiveness, repeatability, and accuracy
there were no ectopic pregnancies or multiple pregnancies, which was similar to laparoscopy and dye. Furthermore, sal-
and no complications. They thought that this procedure pingoscopy and microsalpingoscopy can be performed rou-
appeared to be an effective in patients with clomiphene tinely during the procedure. So he insisted to adopt
citrate resistant PCOS. fertiloscopy as the standard procedure for tubal evaluation.
There were few reports about the complications following This new diagnostic technique requires the use of special
fertiloscopy, let alone the reports about the severe complica- disposable instruments.
13.3 Hysteroscopy in Place of Laparoscopy Bladder mucosa has poor ability to regenerate, cannot shed
and repair periodically as the endometrium; bladder wall is
Hysteroscope has three kinds of telescopes according to dif- thin and more flexible compared with the uterine wall, which
ferent diameter, namely, 1.9 mm, 3 mm, 4 mm, and two types enables the bladder capacity above 400 mL, and even
of telescopes according to its materials, namely, columnar 1000 mL, but even with a wider uterus, the volume of uterine
crystal and glass fiber. The columnar crystal optical tube is cavity seldom exceeds 20 mL; urethral mucosa is more vul-
thin, not resistant to bending and not easy to break under the nerable and more prone to injury than cervical mucosa. The
protection of outer sheath when used as hysteroscope, but the difference in anatomical structure between bladder and
operator should take care when used as laparoscope. The uterus requires the operator to be gentle and slow in the
glass fiber optic tube has a certain anti-bending performance, application of hysteroscopy for cystoscopy so as to avoid
and is more suitable to be used as laparoscope. At present, injury to the urethra and bladder mucosa, and the require-
the trocar has four types, 2 mm, 3 mm, 5 mm, and 10 mm. So ments on equipment and operating area should also be more
when a 4 mm optical tube is inserted with 5 mm trocar, there rigid in order to avoid causing urinary tract infection.
will be leakage of air. 1.9 mm and 3 mm optical tubes have Because the cystoscopy and intrauterine operation are
exclusive trocar, which is more often used in laparoscope. performed mostly in special situations or emergencies, we
Most of the occasions where the hysteroscope is used as lap- need to understand the indications and contraindications for
aroscope are there is laparoscopic monitoring or simple pel- cystoscopy.
vic operation, so that a telescope can be used as either a
hysteroscope or a laparoscope. It can solve the problem of
shortage of laparoscopes and avoid being left unused and 13.4.1 Indications for Hysteroscopy in Place
waste of money due to a purchase of a large number of of Cystoscopy
laparoscopes.
1. Excluding bladder and ureteral injuries in hysteroscopic
and laparoscopic surgery: During cystoscopy, on the one
13.4 Hysteroscopy in Place of Cystoscopy hand, an observation of the integrity of bladder wall and
whether there is active bleeding in the bladder wall can be
Modern hysteroscope and cystoscope share a common origin conducted to verify whether there is injury to bladder
and there have been many similarities in their structure and wall or not. On the other hand, an observation of color
basic manipulation of the instruments so far. For example, and quantity of ureteral jet can help to understand whether
the inspectoscope with hysteroscopy and cystoscopy is made the ureter is damaged or not.
up of sheath and optical tube; there are diverters similar in 2. Etiology of chronic pelvic pain: Since interstitial cystitis
structures at the front end of catheterizing ureteroscope and and endometriosis are the two major causes of chronic
tubal cannulation falloposcope, which can control the up and pelvic pain, there is a strong correlation (the reported cor-
down direction through the controller on the handle, thereby relation as high as 96.6%) between interstitial cystitis and
changing the direction of ureteral catheter or fallopian tube chronic pelvic pain. Therefore, for patients with chronic
catheterization; the electrode on the surgical endoscope is pelvic pain, it is absolutely necessary to undergo two
mostly wire loop electrode and rollerball electrode. However, kinds of endoscopic examination simultaneously—cys-
these two instruments are slightly different, for example, toscopy and hysteroscopy under one anesthesia in order
there is a special structure at the front end of some cysto- to avoid unnecessary delays in the diagnosis and treat-
scopic sheath, which is round and blunt in appearance, and ment so that the patients can have timely and exact diag-
looks like beak, forming an obtuse angle with the rod. It has nosis at first diagnosis.
two types, concaved and convex, which is easy to be intro- 3. Ureteral intubation: In the past, ureteral intubation was
duced into the scope without damage to the urethra, but hys- peculiar to urological surgeons. In gynecological laparo-
teroscope has no such structure. There are two cannula bores scopic surgery, gynecologists may save a lot of valuable
on the handle of catheterizing ureteroscope but there is only time by ureteral intubation via hysteroscope and provide
one cannulation hole with hysteroscope. In the process of important guide in the lysis of pelvic adhesions so as to
introduction of endoscopic body, the obturator with cysto- avoid injury to the ureter. On the other hand, when there
scope will be used more often. These subtle differences do is suspected ureteral injury, ureteral intubation can be
not affect the similarity in their manipulation, which pro- performed for verification. In addition, when inadvertent
vides convenient conditions for the application of hystero- clamping and pulling of ureter induce hematuria in
scope in cystoscopic operation. patients, the placement of double pigtail stent in the ure-
Although bladder and uterus are hollow elastic muscular ter can support and dredge the ureteral wall in order to
organs, these two organs are different in many respects. prevent occurrence of ureteral stricture in future.
4. Monitoring of the treatment of stress urinary inconti- 13.4.3 Matters Need Attention for Using
nence: At present, more and more patients with stress uri- a Hysteroscope as a Cystoscope
nary incontinence choose tension-free vaginal tape (TVT)
surgery or laparoscopic Burch procedure for treatment of There have had incisive descriptions on some of the basic
stress urinary incontinence. These two procedures both skills about cystoscopic examination in the relevant profes-
require cystoscopic examination and monitoring so as to sional books, so here are a few specifications for some prob-
prevent the suture from penetrating the bladder wall and lems to which gynecological endoscopic doctors should pay
understand the postoperative urethral tension and strain- special attention.
ing angles.
5. Cystoscopic examination and auxiliary removal of the 1. When cystoscopy is performed, anesthetic should be
lost IUD: Part of IUD can slip out of the uterine wall, and applied to the mucosal surfaces.
may also penetrate the bladder wall partly or completely 2. The obturator should be used when a larger diameter hys-
into the bladder cavity. Hysteroscopy combined with cys- teroscope is in use for examination.
toscopy can be performed under anesthesia to locate such 3. Whatever diameter hysteroscope is used for cystoscopy,
lost IUD precisely and assist each other in removing the sterile glycerol or liquid paraffin should be coated in the
foreign bodies. front part of the telescope to lubricate the urethra.
6. Other conditions: Serious deformities of the bladder cav- 4. In the process of inserting hysteroscope, the telescope
ity can be found when cystoscopy is performed for uro- should be prevented from slipping into the vagina, par-
logical examination in some female patients with frequent ticularly for older women or the patients whose urethral
urination, especially with frequent nocturnal urination, orifice is narrow and close to the vaginal orifice. If the
and furthermore, uterine fibroids may be detected in these telescope slips into the vagina, it should be disinfected
patients. So, such kind of inspection should also be the carefully after its retrieval. This also suggests that when
gynecological endoscopic doctors’ duty. endoscopy is performed, it is very important to disinfect
carefully the vulva, around the urethra and in the vagina.
5. The bladder base is mostly jacked up by uterus, espe-
13.4.2 Contraindications for Hysteroscopy cially when there is leiomyoma growing in the anterior
in Place of Cystoscopy uterine wall. After the entry of telescope into the urethra,
if the telescope continues to be inserted horizontally,
1. Urethral Stricture: Urethral stricture is the main reason damage to the bladder base may be caused, so operation
for the failure of cystoscopy. If there is severe urethral inside the bladder should be gentle and slow, and the end
stenosis and insufficient consideration about the urethral of telescope should be tilted slightly upward after entry so
stricture before examination, and if the telescope is still as to avoid unnecessary injury.
inserted with force despite resistance, urethral perforation 6. Since the bladder has good elasticity, there is no need to
can be caused. use distention pump during examination. As long as the
2. Too Small Bladder Capacity: If a bladder capacity is less transfusion bottle is hung about 1 m above the operating
than 50 mL, it will not be suitable for cystoscopy. On the table. The irrigating fluid can be saline, 5% glucose solu-
one hand, if the bladder is introduced with some fluid, the tion, 5% mannitol, 3% sorbitol, and 1.2%–1.5% glycine.
patient may have a sense of discomfort, which makes But if there is any electrosurgical operation in the blad-
observations unsatisfactory. On the other hand, if the der, electrolyte-containing fluids like saline should not be
operator has no knowledge of the patient’s bladder capac- used. As the bladder has larger capacity, if the operator
ity, the insertion of the telescope may cause bladder forgets drainage while irrigating, this can cause overfill-
perforation. ing of bladder, resulting in patients’ discomfort. Thus, the
3. Acute inflammatory stage: Hysteroscopy is not advisable fluid inflow and the drainage must be conducted together
when there is acute inflammatory, nor is cystoscopy. and fluid irrigation should be stopped when the folds of
4. If cystoscopy has been done in 1 week, a repeat examina- bladder mucosa are seen to become flat.
tion should be avoided, because the impact of the previ- 7. When the ureteral intubation is to be performed and the
ous examination on bladder has not been eliminated, telescope is being inserted into the urethra, it is important
which may affect the effect of observation. to keep the controller (diverter) in a turned-off or reset
5. The patients with severe systemic disease or renal state so as to avoid scratching the urethra. Intubation
impairment. should not start until the tip of the ureteral catheter is
6. Other conditions: Cystoscopy cannot be performed due to close to ureteral orifice through moving the telescope. Do
such conditions as the bone and joint disease, deformity, not use the diverter frequently in order to avoid injury to
and problem of patient’s position. bladder mucosa. We must see clearly the ureteral orifice
before intubation lest mucosal edema may occur due to a through two-step vaginoscopy in a pubertal virgin girl with miliary
tuberculosis. J Minim Invasive Gynecol. 2014;21(2):176–7.
forceful intubation.
6. Feng Z, Shao J. Practical hysteroscopy. Shanghai: Shanghai
8. Since the ordinary hysteroscope is a rigid telescope with Medical University Publishing House; 1999. p. 120. Chinese.
a smaller and fixed angle, a fiber hysteroscope should be 7. Fernandez H, Watrelot A, Alby JD, Kadoch J, Gervaise A, deTayrac
chosen if an all-round inspection of the bladder is R, Frydman R. Fertility after ovarian drilling by transvaginal ferti-
loscopy for treatment of polycystic ovary syndrome. J Am Assoc
required. Take Olympus hysteroscope for example,
Gynecol Laparosc. 2004;11(3):374–8.
HYF-XP fiber hysteroscope has a telescope of 3.1 mm 8. Garbin O, Kutnahorsky R, Göllner JL, Vayssiere C. Vaginoscopic
in diameter and 100° of view angle, while HYF-IT fiber versus conventional approaches to outpatient diagnostic hysteros-
hysteroscope has a view angle up to 120°, with biopsy copy: a two-centre randomized prospective study. Hum Reprod.
2006;21(11):2996–3000.
capability and the telescope 4.9 mm in diameter. Both
9. Gordts S, Campo R, Rombauts L, Brosens I. Transvaginal salpin-
are very suitable for all-round inspection of the goscopy: an office procedure for infertility investigation. Fertil
bladder. Steril. 1998;70(3):523–6.
9. Through an observation of the color and quantity of ure- 10. Gordts S, Watrelot A, Campo R, Brosens I. Risk and outcome of
bowel injury during transvaginal pelvic endoscopy. Fertil Steril.
teral jet, we can understand whether the ureter is impaired
2001;76(6):1238–41.
or not. If the patient is given intravenous infusion of 1 or 11. Gorts S, Campo R, Brosens I. Office transvaginal Hydrolaparoscopy
2 ampoules of methylene blue solution, which can make for early diagnosis of pelvic endometriosis and adhesions. J Am
the urine turn blue, it will be easier to observe the patency Assoc Gynecol Laparosc. 2000;7(1):45–9.
12. Guida M, Di Spiezio SA, Acunzo G, et al. Vaginoscopic versus tra-
of the ureter. In such a case, it is more appropriate to
ditional office hysteroscopy: a randomized controlled study. Hum
choose 5% glucose as the irrigating fluid, because saline Reprod. 2006;21:3253–7.
is easy to be mixed instantaneously with urine containing 13. Guo H, Lan J, Zhao S, Gao J, Bie Y, Hu X. Comparison of no-touch
blue color, it will be not easy for observation in a blue hysteroscopy with traditional hysteroscopy. Chin J Obstet Gynecol.
2011;46(4):281–2. Chinese.
vision field. However, 5% glucose solution is not easy to
14. Guo Y. Intrauterine urology. Beijing: People’s Medical Publishing
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20. Watrelot A, Dreyfus JM, Cohen M. Systematic salpingoscopy and
Suggested Reading microsalpingoscopy during fertiloscopy. J Am Assoc Gynecol
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Ginecol Obstet. 2008;30:25–30. 22. Watrelot A, Gordts S, Andine JP, Brosens I. Une nouvelle approche
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deux complications au cours du drilling ovarien par fertiloscopie 23. Watrelot A. Place of transvaginal fertiloscopy in the management of
[About two complications of ovarian drilling by fertiloscopy]. tubal factor disease. RBM Online. 2007;15:389–95.
Gynecol Obstet Fertil. 2003;31(10):844–6. French. 24. Xia EL, Felix W, Li Z. Gynecologic endoscopy. Beijing: People’s
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Hysteroscopy Training
14
Enlan Xia and Xiaowu Huang
Before widespread clinical application, any kind of diagnos- 2. To familiarize with the instruments and equipment, and
tic and treatment technique must involve a set of systematic master the indications, contraindications, and
learning methods to guide operators to understand and grasp complications.
its operating principles step by step. Through clinical prac- 3. To learn the basic knowledge through the relevant data,
tice, its application methods, operating skills, and safety are photos, and videos and master operating skills by attend-
constantly improved and perfected. Therefore, systematic ing workshops, seminars, and tutorials.
training is important for the completion and implementation 4. To practice hysteroscopic examination in simulation on
of endoscopic training program, and all the gynecologists to the uterine model and removed uterine specimens, and
be engaged in this program must be qualified in this planned then practice diagnostic hysteroscopy in living bodies
standard training so as to achieve the expected level of prior to diagnostic curettage or vaginal hysterectomy.
expertise. Only when the operators are completely proficient in hys-
teroscopic examination, can they start the practice of hys-
teroscopic tubal cannulation and hydrotubation.
14.1 Training Procedures 5. To learn hysteroscopic surgeries after being proficient in
hysteroscopic diagnosis and treatment.
The training of hysteroscopic operating system should start
with a comprehensive understanding of its varied instru-
ments and their components, followed by the practice on the 14.2 Requirements for an Operator
models, animal specimens, isolated uterus, or other simu-
lated environment in order to achieve hand-eye coordination Hysteroscopy is a specific procedure in gynecological field.
and learn to complete the surgical procedure through endo- Its safety and efficacy are closely related to the operating
scopic images. On this basis, the gynecologists must learn its level of operators. Hysteroscopic surgery needs special
indications, contraindications, and potential complications. instruments. During surgery, doctors operate by using mon-
Through attending workshops, seminars, tutorials and read- ocular view or 2D images on a television screen instead of
ing relevant books and their matching atlas in combination three-dimensional observation, which adds difficulty to
with simulated training, the unity of theory and practice can operation. So, operators must pass strict technical training to
be achieved. Its training procedures are as follows. achieve a safe procedure. The requirements for operators in
hysteroscopy are as follows.
1. To acquire relevant knowledge in this field through read-
ing and reviewing the relevant teaching materials about 1. Operators must have good basic surgical trainings, in-
hysteroscopic operation such as atlas, teaching video, depth knowledge about anatomical uterine markers, and
slide and CD, etc. Only when gynecologists have a good rich experience in open surgery, and can handle the surgi-
understanding of the uterine anatomy and pathology, can cal complications and intraoperative accidental events.
they distinguish normal tissues from diseased ones, and 2. Operators must have sufficient experience and strong
then make a definite diagnosis. ability in diagnostic hysteroscopy.
3. Operators must have skillful hands, can coordinate hands,
feet, eyes, and brain to work in harmony, can manipulate
E. Xia (*) · X. Huang the resectoscope proficiently and have a good control of
cutting depth.
Beijing, China

434 E. Xia and X. Huang
4. Operators must have a clear and quick mind to deal with 1. Place the electric cutting loop at the distal side and on the
various accidental situations rapidly during the surface of the tissues to be excised. Before moving the
operation. loop electrode to start cutting, the first step is to step on
5. Operators must have knowledge of energy source so as to the foot pedal. Then moving the cutting handle or spring
clear troubles timely. when the hands have a sense of cutting, and cutting into
tissues according to the requirements and resecting the
tissues based on the required cutting depth. The moving
14.3 How to Teach Beginners speed is usually 1 cm/s.
2. After each cut, there should be tissues visible from a cut-
Because hysteroscopic surgery may be rather difficult and ting surface. Only when the loop electrode moves into the
performed in a very narrow vision field, it is not easy for sheath and the foot is released, will it be possible to resect
beginners to learn. So attention should be paid to the follow- the tissues fully.
ing points. 3. Generally, the resected tissue appears to be stripped. It is
slightly thinner at either end and thicker in the center, like
1. To begin with, do some resection exercises for a certain a small boat. The thickness of tissue slice is directly pro-
period of time on the real objects, such as meat, apple, portional to the placement depth of loop electrode, and its
soap, or corpse so as to manipulate the resectoscope and length depends on the moving distance of the loop elec-
resectional techniques of tissue proficiently. trode and the endoscopic sheath.
2. To observe how teachers handle electric cutting with the 4. Taking the internal cervical os as a pivot, the depth of cut-
aid of teaching endoscope or TV video. ting is adjustable.
3. Under the guidance of teachers and surveillance of teach- 5. If the tissue to be resected is thick, the operator should
ing endoscope or TV, the beginners can perform short- lean the tip of resectoscope sheath slightly forward so that
time electric coagulation and (or) resection of a small the loop electrode may cut into the tissue and then cut
amount of cervical tissues. slightly and deeply in arcing movement until the end of
4. After a good command of basic operations, the beginner cutting. Then raise the sheath slightly, and excise the tis-
may choose to perform electroresection in a slightly sue successfully.
larger uterus monitored by the teacher through a teaching
endoscope or television. If only a small portion is excised Hysteroscopic training must start from a simple proce-
in half an hour, the teacher should change position with dure to complex ones. Simple procedures include removal of
the beginner in order to try to complete the operation IUD, polyps, foreign bodies, etc.; complex procedures
within the second half hour. include division of intrauterine adhesions, resection of sep-
5. When the beginner starts to perform electroresection, tum or myoma, and resection of endometrial polyps or
after the completion of the operation, the teacher should endometrium.
conduct inspection and supplements.
Suggested Reading
14.4 How to Cut Tissues
1. Xia EL. Specifications of gynecological endoscopic operation. Chin
J Obstet Gynecol. 1997;32:267–75.
In hysteroscopic surgery, electric cutting is a crucial step,
and also a key indicator to evaluate the success or failure of
operation and operator’s level. So, how to cut tissue is the
focus of training.
The Future of Hysteroscopy
15
Enlan Xia
In the past 30 years, rapid development of hysteroscopic also makes a clearer vision field, which extends its therapeu-
technique and great progress in its equipment have turned tic indications. And more and more various kinds of auxil-
hysteroscopic examination and surgery into an effective iary devices and electrodes will emerge, and hysteroscopic
means of diagnosis and treatment of intrauterine lesions for examination and surgery will be more suitable in an outpa-
gynecologists. It can be foreseen that there is a great deal of tient setting. With the simplification of procedure, this sur-
hope for hysteroscopy. Not only the indications for hystero- gery will be more practical, more secure and the operative
scopic diagnosis and treatment are well established nowa- time will also be shortened, and its accuracy will also be
days, but they have also been extended and have replaced improved. These tendencies will lead to simplification of
some other operations performed by gynecologists, such as many surgical procedures. With the advent and application
curettage, removal of uterine submucous myoma by hyster- of ultrasonography control technology and with the perfec-
otomy and blind division of intrauterine adhesions, and so tion and practicality of the modern operating room facilities,
on. The main aspect for future research will be the new sec- labor intensity of doctors will be greatly reduced so that the
ond generation endometrial ablation technique. The ideal range of diagnostic and operative hysteroscopy will be fur-
second generation technique should be accomplished more ther extended.
easily, require less skills and less training, and can be done In 2001, scholars at the tenth annual meeting of the
under local anesthesia, but its effect can be comparable to International Society for Gynecologic Endoscopy held in
classic hysteroscopic surgery, which can be adapted to all San Francisco of America pointed out that, by 2025, most of
intrauterine operations including fibroids, and there are gynecological operations will be replaced by endoscopic
fewer complications compared with TCRE and EA. There is operation.
still more need for analysis of randomized controlled trials We must learn from history, continue to innovate and cre-
on various endometrial ablation techniques as much as pos- ate so as to make medical techniques simpler, safer, and
sible so as to evaluate its effectiveness and safety. If there is more beneficial to patients. Since the initial objective has not
no solid credible evaluation, new technique and new equip- yet been achieved completely, the innovation and creation in
ment cannot be applied routinely in clinic and be introduced hysteroscopy should never stop.
in the market. In the treatment of obstetric and gynecological
diseases, the costly endometrial pretreatment with drugs has
gradually given way to mechanical pretreatment for eco- Suggested Reading
nomic reasons.
The future begins today. Everything will move forward as 1. Baggish MS, Valle RF. Future of hysteroscopy. In: Baggish MS,
Barbot J, Valle RF, editors. Diagnostic and operative hysteroscopy.
time goes by. Future instruments will be more simplified and 2nd ed. St. Louis: Mosby; 1999. p. 391–401.
future energy will be more secure. Intraoperative use of 2. Parkin DE. Endometrial resection and ablation: past, present and
micro-morcellator not only disturbs uterine distention, but future. Gynaecol Endosc. 2000;9:1–7.
E. Xia (*)
Beijing, China

Digital Storage and Application
of Endoscopic Image 16
Baijiang He
The storage and application of endoscopic image data had 16.1 Basic Concept
been problems difficult to resolve properly before the intro-
duction of computer technology. In order to save a valuable A static image is composed of a large number of pixels
picture on the monitor as a static image, it is unimaginable arranged in a matrix form. The smaller the pixels per unit
to directly face the monitor and shoot. Some endoscopic area is and the more number of pixels is, the higher the image
manufacturers developed special equipment for shooting resolution will be, and it looks more realistic as we see. A
the endoscopic images with optical camera. After being dynamic image is composed of a series of rapid continuous
filmed and processed, photographs are created for preserva- play of static images based on the theory of visual persis-
tion. The dynamic images can only be stored in video tape, tence. Usually, a film consists of 24 static frames per second
CD, or DV (digital video cassette). The shortcomings of and TV consists of 25 frames per second. Human eyes can-
doing so are that there will be loss in video quality after not detect such rapid image shift but can produce a smooth
being preserved for long term or being replicated for many sense of reality. Every pixel of color image is formed by the
times, and that it is not possible or difficult to effectively color and luminance information. The analog signal is to use
edit and modify freely without professional equipment. For the voltage values to simulate the color and brightness of
example, if we would like to produce a short teaching video each pixel while the digital signal is to use binary digits to
about endoscopic surgery, there was a need to edit the origi- represent the color and brightness of each pixel. Either ana-
nal video data, such as editing videos, adding captions, and log or digital signals, as long as they follow their putative
putting both narration and music. Its completion not only coding rules, can encode any static and dynamic image and
requires professional equipment worth of hundreds of thou- transfer the codes through the transmission media to the des-
sands of dollars in the television station or publishing house tination and represent them as video image. Analog signals
but also assistance of the professional and technical may be subject to outside interference in the process of
personnel. encoding, transmission, transcription, and representation,
Since the rapid development of computer multimedia resulting in mild offset voltage value, thereby leading to dis-
technology, there have been radical changes in the situation. tortion in the represented image. Since digital signals have
Especially, today’s desktop computer performance is similar only two values of 0 and 1, and there is check mechanism in
to small video workstation performance. So, we are fully the every process above, it will not be distorted no matter
conditioned to conduct endoscopic static and dynamic image how many times it is transcribed or how far it is transmitted.
collection in the hospital with simpler devices, and edit and Theoretically speaking, as long as the original capturing rate
modify in the late stage so as to produce the surgical atlas is high enough and data has not lost (lossy compression) in
and short teaching videos of our own style. Mastery of this the late procession, the digital signal can be taken to be
technique has become one of the necessary skills for endo- exactly the same image as the original at any time, on any
scopic doctors. occasion and in any form. This is the reason why the digital
image technique is superior and will eventually replace sim-
ulation technique.
At present, the host computer with endoscopic imaging
system can provide three kinds of analog video signal out-
put, namely, composite video, Y/C, and RGB, in which the
B. He (*) signal quality is in succession upgraded. In some high-end
Endoscope Marketing Department, Olympus (Beijing) Sales and
models, YPbPr output can also be provided. The digital
Service Co., Ltd, Beijing, China

438 B. He
storage and application of these analog video signals must 16.3 Storage and Application of Dynamic
go through analog-to-digital conversion, and this process is Images
completed in the video capture card (connected to the card
in the computer PCI expansion slot). The digital image The digital processing of dynamic images is complex. When
quality formed depends on the type and quality of original we receive Video or Y/C analog video signals from endo-
analog video signals and the quality of analog/digital con- scopic imaging host computer, they are input into the video
version equipment (i.e., video capture card). With advances signal capture card, and then the video signals are captured
in technology, we can obtain very easily the universal digi- and encoded, thus forming the video files in the computer
tal video signals from the endoscopic instruments so that hard disk. Later, we can use the corresponding player soft-
the formation of endoscopic image from production to final ware to play on the computer screen or projector, and also
application is a purely digital process. Now we have been use the software and (or) hardware for editing.
able to record digital images in multiple formats through Before the digital video files cannot be effectively com-
extensive recording media. For example, the pioneer of pressed with high quality, huge amounts of data may over-
digital video signal host computer—Olympus Corporation, load the computer system. The data volume of digital video
after launching VISERA camera system which meets the signals up to 216 MB/s (component video) or 142 MB/s
requirement for a variety of endoscopic surgeries, devel- (composite video) can only be processed in high-end digital
oped the latest Exera II system in accordance with 1080i video workstation. Nowadays, the digital video compression
HDTV standard. They can all provide a universal digital algorithm is becoming more mature day by day and the PC
video signal output, IEEE1394. performance is improved constantly. All these have made the
processing of the digital video files in a desktop computer or
a notebook computer possible. The common compression
16.2 Storage and Application of Static formats are Motion-JPEG, MPEG1, MPEG2, MPEG4, as
Images well as VCD/ MPEG1 format and DVD/MPEG2 format.
The static image formed instantly in an endoscopic imag-

ing host computer may be saved as a file in a universal com-
puter format and used for exchange. Such image file can be
added directly to the PowerPoint slide for academic
exchanges, and can be directly used for publication in a
book, can be printed as photos, but also can be edited and
modified with software like PhotoShop, for example, add-
ing annotations.
OTV-S7 digital camera system (Fig. 16.1) produced by
Olympus Corporation can directly save the images in a size
of 3.7 mm × 4.5 mm × 0.1 mm SmartMedia card (Fig. 16.2)
in a JPEG or TIFF format. A 256 MB SmartMedia card can
hold about 2400 low-quality images, or about high-quality
960 images. These image files can be stored into the hard
disk or CD-ROM for various uses.
Fig. 16.1 OTV—S7 Fig. 16.2 SmartMedia card

16 Digital Storage and Application of Endoscopic Image 439
Different video cards offer different combinations of synthesize, add captions or sync sounds by using the equip-
three different functions: capture, compression, and editing ment like editing machine, subtitling machine and mixer
(thus named differently), offer different number and types of which are worth hundreds of thousands of yuan, and all oper-
interfaces (composite, Y/C, component, IEEE 1394) and ations must be implemented in strict accordance with the
offer different compression algorithms, so different types of timing sequence instead of at will. Nonlinear editing system
video files may be generated for selection according to actual is to code the digital video source by using high-performance
needs. Generally, to provide one or two composite or Y/C computer and then to store them in the high-speed digital
signal input is suitable for hospital use in any one format or hard disk. When editing, creating stunts, adding captions and
more formats among MPEG1, VCD, MPEG2, Motion-JPEG sync sounds are being conducted, it is actually calculating
and AVI, and the hardware video editing card for special and rewriting the digital codes. Then, the dynamic images
effects is essentially not needed. MPEG1 and VCD files can generated from these codes are played on computer, televi-
be directly burned into VCD disk, and simple operation can sion, projectors, and other devices. The digital images will
be completed with VideoPack burning software. Its weak- not be distorted even with frequent transcription and passage
ness is ordinary effect with playback on computer. MPEG2 of time. During the processing, there is no need to be con-
is DVD quality digital video format. PC has optical disk fined to the video data sequence, so the nonlinear editing sys-
drive supporting DVD burning function, which can make tem has incomparable superiority compared with the
DVD disk with the appropriate software. Motion-JPEG and traditional linear editing system. More important is that very
AVI is a commonly used video editing format with very high little investment in equipment can allow the work to be com-
image quality, its frame accurate editing can be realized, but pleted in high quality, which would require 10 times the
the file is bigger, the requirement for computer system is price if the original equipment is used. Now in the profes-
relatively high, and its operation is slightly more complex. sional institutions, nonlinear editing system has been widely
Therefore, if we want to use the most convenient way to get used and has also become readily available in individual
VCD disk, the first scheme can be adopted; if we wish to applications.
obtain higher playback quality on a computer screen or pro- The basic nonlinear video editing system is made up of
jector, the second type of scheme can be adopted; the third the high-performance computer (including high-speed video
scheme is applicable to relatively professional users, which storage system), analog (digital) video (audio) capture, edit-
can be used to edit admirable personalized teaching short ing, playback device, optical disk recorder, scanner and the
videos. In addition, when choosing video card, we should corresponding software package, and other equipment can
not choose one with recording time limits, otherwise it will be added depending on the specific uses. The video process-
bring us trouble in the recording and processing in the late ing computer has higher requirements on the system perfor-
stage. No matter which kind of format is adopted in file com- mance, in addition to good overall performance, still a large
pression, the most frequent needs are to edit the surgical pro- memory space, high speed and large capacity hard disk and
cess and remove unnecessary parts, and add text captions stronger multimedia processing capability are needed, to
and sync sounds as well. These operations can be completed which attention should be paid in the configuration of a com-
by using Adobe Premiere or Ulead Media Studio, VideoStudio puter system.
(true to like), and others. And we can also choose from var-
ied domestic software, which is very easy to use.
If the endoscopic imaging host computer provides 16.5 Clinical Applications of Digital Video
IEEE1394 digital video output (such as Olympus Visera or Image Data
Exera II system), it can be connected directly with IEEE
1394 (Firewire) interface on the notebook computer, and 1. The unedited original surgery data can be burnt to a CD
digital video capturing and simple editing can be conducted for long-term preservation or play in VCD and DVD
by using Windows MovieMaker software. This is the most player at any time.
convenient solution. 2. The edited endoscopic video images, X-ray imaging,
ultrasonography imaging, live surgery or surgery-
explained video can be used for academic exchanges,
16.4 Concept and Composition teaching, demonstration and being made into a CD-ROM
of Nonlinear Editing System for permanent preservation.
3. The live video image or video image data may be trans-
Colloquially, nonlinear editing system is the incorporation of mitted through the broadband network so as to accom-
hardware and software system for digital processing of the plish video conferencing, telemedicine, and online
above video signals. The traditional image editing is to teaching.
record the analog video signals to videotape, and then edit,
ppendix 1: Routine Orders
A
in a Hysteroscopic Ward
Doctor’s Orders on Admission 5. Prescription orders according to the patient’s conditions,

antibiotics when needed.
Standing Orders Notes: Cervical ripening of (3) and (4) can be replaced
1. Gynecological Usual Care. by the following methods:
2. Nursing care second grade. 1. Misoprostol 400 μg is inserted into posterior fornix of the
3. General diet. vagina 2 h prior to the operation.
4. Prescription orders according to the patient’s conditions 2. Phloroglucinol (smooth muscle antispasmodic agent),
and requirements. 40–80 mg, is applied by intravenous drip 15 min prior to
operation, which should be finished in 5 min.
Stat Orders
1. Routine blood tests, ABO and RH blood grouping. Postoperative Orders
2. Routine urine tests. 1. Postoperative care following TCR__ under anesthesia.
3. Liver and kidney function tests, biochemistry tests, and 2. First grade nursing care for 1 day, then second grade nurs-
lipid blood tests. ing care.
4. Tests for surface antigen of the hepatitis B virus (HBV). 3. Fasting for 6 h, then regular diet.
5. Coagulation tests (four items). 4. Prescription orders according to the patient’s conditions,
6. Cervical smear (which can be ignored if having TCT including antibiotics.
results). 5. Orders for special conditions and treatment.
7. Tests for vaginal cleanliness, Monillia, and bacterial 6. 1–3 days after operation: routine blood tests and leuko-
vaginosis. cyte differential count (DC).
8. Chest X-ray PA (posteroanterior) & LAT (lateral). Note: please write down the abbreviated English name
9. Electrocardiogram (ECG). of the surgery in the first item.
10. Abdominal pelvic ultrasonography (within 1 month).
11. Gynecological examination. pecial Management After TCRS and TCRA
S
12. Tumor-associated antigens (in patients with adnexal 1. Vulva washing one or two times (if a balloon catheter is
mass): AFP, CEA, CA125, CA199 retained).
And: serum HCG, AKP, LDH. 2. Hormone replacement therapy (For reference).
13. Tests for hepatitis C virus (HCV) antibody and trepo- (a) Estradiol Valerate (Progynova) 2 mg, take orally
nema pallidum hemagglutination assay (TPHA) and (p.o.), twice a day (b.i.d), from the fifth day of men-
HIV antibody. struation and continued for 21 days.
(b) Provera (medroxyprogesterone acetate) 4 mg, p.o.,
b.i.d, or Dydrogesterone 10 mg, b.i.d, taken from the
Hysteroscopic Operations 19th day of the menstrual cycle for 7 days.
(c) A menstrual period may resume 3–7 days after simul-
Orders on the Day Before Operation taneous discontinuation of these two drugs. In the
1. Time and type of operation. next menstrual cycle, the medication is administered
2. No eating and drinking on the morning of operation. the same as the last, and there are two artificial cycles
3. Insertion of cervical osmotic tent. in total.
4. Anal tampon with indomethacin 100 mg 30 min before 3. Second-look hysteroscopy is performed 4 weeks after
insertion of osmotic tent. operation.

E. Xia (ed.), Practical Manual of Hysteroscopy, https://doi.org/10.1007/978-981-19-1332-7
442 Appendix 1: Routine Orders in a Hysteroscopic Ward
Conditions on Discharge 9. Antibiotics and fluid according to the patient’s conditions

1. Histological results. (postoperative medications).
(a) There must be histological report in principle.
(b) The patient should be informed and given explana- Postoperative Orders
tion by her doctor. 1. Postoperative care for the surgery and anesthesia.
2. Routine blood test is normal. 2. First grade nursing care for 3 days, then second grade
3. The temperature is normal. The patient’s condition is nursing care.
stable and there is no much bleeding. 3. Fast for 6 h, then semi-liquid diet, regular diet 2 days
4. A discussion must be held before an early discharge from later.
hospital. 4. A companion for 3 days.
5. The catheter is retained for 24–48 h (according to the
recautions After Hysteroscopic Operation
P patient’s conditions), then removed.
1. It is normal that there is a small amount of bleeding and 6. Scrubbing vulva once a day (after hysterectomy, usually
discharge within 2 months after operation, during which for 3 days).
sexual intercourse should be banned. If there is too much 7. Antibiotics and liquid according to the patient’s condi-
bleeding and discharge, timely follow-up is needed. tions (see clinical medications).
2. If there is bleeding in patients within the third month after 8. Timely discontinuation or modification of medication
resection of endometrium, it is menstrual blood. according to patients’ conditions.
3. Outpatient check-up should be conducted in the first and 9. Removal of sandbag after 6 h of abdomen compression.
third month after operation, and re-check should be fol- 10. In the patient with an abdominal drainage, its removal is
lowed once every half a year thereafter. determined by her condition and materials drained.
4. TCRE may produce certain contraceptive effects with a 11. 1–3 days after operation:
low failure rate like all other contraceptive measures, so if (a) Routine blood test and leukocyte DC.
there is abnormal condition, please come quickly to the (b) Routine urine test (10 items).
hospital for a diagnosis. However, this does not belong to (c) Changing the abdominal wound dressing.
the scope of family planning.
5. The patients may get pregnant after removal of IUD recautions After Operation
P
2 months following resection of septum. 1. An outpatient check-up should be conducted 1 month
6. The patients may get pregnant 3 to 6 months after resec- after surgery.
tion of submucous myoma. 2. Sexual intercourse should be banned within 1–2 months
7. Menstruation can return to normal in patients 1 month or after total hysterectomy and 1 month after other surgery,
so after TCRP, TCRA, and TCRF. or follow the doctor’s advice.
8. Comply with doctor’s orders given other conditions. 3. There might be a small amount of vaginal bleeding
2–4 weeks after hysterectomy. If the bleeding volume is
equal to that of a menstrual period or there is vaginal dis-
Laparotomy Surgery charge, please return quickly to see the doctor.
4. The patient has a poor physical strength within 3 months
Orders on the Day Before Operation after hysterectomy, and returns to preoperative health sta-
1. Time and type of operation, and method of anesthesia. tus after 6 months, and is significantly improved in health
2. Skin preparation. status 1 year later.
3. 200–400 mL of blood preparation (according to the 5. Menstruation may return to normal about 1 month after
patient’s conditions). myomectomy. Pregnancy is feasible after 1–2 years of
4. Semi-liquid diet on the night before operation, and no contraception.
eating and drinking on the next morning. 6. The regular menstruation may be resumed about 1 month
5. Enema with drugs (glycerin bowel enema) twice at the after adnexa surgery.
night before surgery and the morning of surgery. 7. Comply with doctor’s orders given other conditions.
6. Cleaning the vagina with 0.5% povidone-iodine once at
3 p.m. before surgery and once on the morning of Conditions on Discharge
surgery. 1. The incision heals well.
7. Antibiotics are administered via intravenous infusion 2. The temperature is normal for more than 2 days.
30 min prior to operation (see clinical medications). 3. The routine blood and urine tests are normal.
8. Urethral catheterization on the morning of surgery. 4. Record of gynecological examination before discharge.
Appendix 1: Routine Orders in a Hysteroscopic Ward 443
5. There must be histological report. In special cases, the Postoperative Orders

patient should obtain permission before discharge from 1. Postoperative care for the surgery and general
hospital after discussion. The patient should be informed anesthesia.
and given explanation by her doctor. 2. First grade nursing care for 1 day, then second grade nurs-
ing care.
3. Fast for 6 h, then semi-liquid diet, regular diet 2 days
outine Orders of Diagnostic or Operative
R later. (Fast for 6 h, then regular diet after diagnostic
Laparoscopy laparoscopy.)
4. A companion for 1 day.
Orders on the Day Before Operation 5. The catheter is retained, and is removed after intravenous
1. Full liquid diet on the morning and afternoon, and fasting infusion.
on the night before surgery. Nil by mouth on the morning 6. Antibiotics according to the patient’s conditions (see clin-
of surgery. ical medications). If necessary, an indwelling catheter is
2. Time and type of operation under general anesthesia. used. If there is external suture, stitches are removed in
3. Liquid paraffin 30 mL, or polyethylene glycol electro- 5–7 days.
lytes powder 2–3 boxes, 4:30 p.m. p.o., or soapsuds or 7. If laparoscopic cervical cerclage is performed in mid tri-
glycerin enema once the night before surgery and once mester of pregnancy, medications should be prescribed as
the morning of surgery. follows: 5% glucose (GS) 250 mL with 25% Magnesium
4. Cleaning the umbilical stump. Intravenous antibiotics Sulfate 5 g, i.v. given within 1 h. Then 5% GS 500 mL
injection (i.v.), 30 min prior to operation (see clinical with 25% Magnesium Sulfate 7.5 g, i.v. given within
medications). 4–6 h. Respiration and patellar reflex should be moni-
5. Postoperative medications (supplement fluid 1000– tored. Medications on the next day prescribed according
1500 mL i.v.). to patient’s condition.
6. Medications according to the patient’s conditions. 8. In the patient with an abdominal drainage, its reservation
and removal is determined by her condition and materials
Bowel Preparation drained.
1. Bowel preparation is needed when the surgery might be 9. 1–3 days after operation:
associated with intestines. (a) Routine blood test and leukocyte DC.
2. The surgeries requiring bowel preparation include: (b) Routine urine test (10 items).
(a) LAVH, large ovarian cyst. (c) Changing the abdominal wound dressing.
(b) A history of abdominal surgery.
(c) Chocolate cyst with suspected adhesions. Conditions on Discharge
(d) There may be intraoperative bowel injury. 1. The incision heals well.
2. The temperature is normal for more than 2 days.
ethods of Bowel Preparation
M 3. The routine blood and urine tests are normal.
(See Table- Appendix 1) 4. Record of gynecological examination before discharge.
5. There must be histological report. In special cases, the
Three Days Before Operation patient should obtain permission before discharge from
1. Semi-liquid diet. hospital after discussion. The patient should be informed
2. Oral medicines: (1) metronidazole 0.4 g, 3 times a day and given explanation by her doctor.
(t.i.d). (2) gentamicin 80 mg, b.i.d.
Two Days Before Operation

1. Total liquid diet. Routine Orders of Transvaginal Surgery
2. Senna 10 g, taken as tea, once a day for 2 days.
reoperative Preparation for Transvaginal
P
On the Day Before Operation Surgery
1. Nil by mouth. 1. 1/5000 potassium permanganate solution, hip bath, b.i.d.
2. 2500–3000 mL rehydration. (4 g potassium permanganate on the doctor’s order).
3. Liquid paraffin 30 mL, or polyethylene glycol electro- 2. The pubic hair should be shaved clean before a hip bath.
lytes powder 2–3 boxes, 4:30 p.m. p.o.; or soapsuds or 3. Vagina scrubbing, b.i.d. for 3 days before surgery (stand-
glycerin enema 1–3 times at 3:30 p.m. before surgery and ing orders).
6:30 a.m. on the day of surgery.
Notes: if colporrhaphy is done in old women, estrogen Fluid replacement

should be applied for period of time to pretreat the vaginal 1. MG3 (Compound Electrolytes and Glucose Injection)
mucosa. 500 mL.
2. 5% G.S. 500 mL.
rders on the Day Before Operation
O 3. 10% G.S. 500 mL q.i.d (once a day) iv drip.
1. Time and types of operation and anesthesia. 4. Vit C 1 g.
2. Skin preparation.
3. 200–400 mL blood is prepared (according to the patient’s
conditions). Addendum
4. Semi-liquid diet on the night before operation, nil by
mouth on the morning of operation. 1. Pretreatment of hysteroscopic surgery (Or apply intraop-
5. Soapsuds enema once the night before surgery and once erative suction-mechanical thinning of endometrium).
the morning of surgery. (a) Gestrinone 2.5 mg p.o., twice per week. (stat order)
6. Antibiotics (see clinical medications) and fluids are pre- (b) GnRH-a once per 28 days.
scribed according to the patient’s conditions, i.v. 30 min 2. Progesterone hormone therapy for endometrial carci-
before operation. noma (for reference).
tanding Orders After Transvaginal Surgery

S Medroxyprogesterone 100 mg p.o. b.i.d × 3 months
1. Postoperative care for the surgery and anesthesia. Progesterone caproate 250 mg im q.i.d × 3 months
2. First grade nursing care for 3 days, then second grade Medroxyprogesterone 250 mg p.o. q.i.d × 3 months
nursing care. Medroxyprogesterone 500 mg p.o. q.i.d × 3 months
3. A companion for 3 days. Medroxyprogesterone 100 mg im q.i.d × 3 months
4. The catheter is retained for 24–48 h (according to the BMI body weight/height2, the range of normal value is from 22 to 24
patient’s conditions). im intramuscular
5. Vulva scrubbing 1–2 times a day (according to the
patient’s conditions). 3. Medication routines for atypical endometrial hyperplasia
6. Fast for 6 h, then semi-liquid diet, regular diet 2 days following resection of endometrium (For reference).
later. (a) Mild: medroxyprogesterone 30 mg, q.i.d × half a
7. Antibiotics (see clinical medications) and other drugs are year.
prescribed according to the patient’s conditions. (b) Moderate: medroxyprogesterone 100 mg, q.i.d × 3
months, and half dose for another 3 months.
(c) Severe: Medroxyprogesterone 250 mg, q.i.d × 3
ocuments Provided to the Patients
D months, and half dose for another 3 months.
on Discharge (d) Reexamination is done every 3 months including sec-
ond look hysteroscopy and target biopsy.
1. A certificate of in-patient diagnosis, on which the admis- Notes: The conservative treatment of endometrial can-
sion date, the discharge date, the surgery performed, the cer should be well explained and the patient’s con-
diagnosis and the duration of restoration should be stated sent must be obtained. It can apply a combined
clearly. treatment of GnRH-a and LNG-IUS, and diagnostic
2. Writing postoperative precautions, medications, and time hysteroscopy and curettage for histological examina-
of check-up on patient’s medical recording book. tion should be performed every 2 to 3 months
3. Medical files including discharge abstract. 4. Hemostasis.
(a) Hemostatic triple injections (5% GS
500 mL + Etamsylate 3.0 g + Vit C 3 g + p-amino-
Clinical Medication methyl benzoic acid 0.3 g), iv drip, q.i.d.
(b) Hemocoagulase 1 U, im or iv.
Antibiotics in Common Usage (c) Tranexamic acid and sodium chloride injection,
1. Cefoxitin 2.0 g diluted in 0.9% N.S. 100 mL, iv drip 100 mL, iv drip.
(intravenous drip), Bid. 5. Use of anticoagulants in patients with artificial valve
2. If the patient is allergic to penicillin or cephazoline, alter- replacement.
natives may be: (a) Patients with mechanical heart valves need lifelong
Clindamycin 0.6 g iv drip Bid. anticoagulation (warfarin).
(b) The use of anticoagulants should be regulated accord-
ing to the patient’s conditions.
(c) The international normalized ratio (INR) of pro- in a month. The INR value is maintained between 2
thrombin time may be 1.5–2 times of normal value and 3.
after taking anticoagulants. If it is lower than 1.5 6. One-day treatment program for ovarian cancer (CAP).
times, it should be appropriate to increase the dosage, (a) 5% G.N.S. 1000 mL, from the night before surgery
and if it is 2.5 times or higher, the dosage should be till the next morning.
appropriately reduced. (b) 5% G.N.S. 250 mL+ furosemide 20 mg, by small pot.
(d) During medication, attention should be paid to bleed- (c) 20% Mannitol 125 mL (finishing in 30 min).
ing tendency; if there is skin petechiae, epistaxis, gin- (d) 5% G.N.S. 750 mL+ amycin 50 mg (into 50 mL N.S.
gival bleeding, hematuria, and other symptoms, it solution), by small pot.
should be appropriate to reduce the dosage, and stop (e) 5% G.N.S. 500 mL + D.D.P 50 mg (into 50 mL N.S.
if necessary (INR > 5 or 2.5 times more than that of solution), by small pot.
average person). Vitamin K1 antagonists cannot be (f) 5% G.N.S. 500 mL + CTX 500 mL (into 50 mL N.S.
injected casually unless in a special emergency. solution), by small pot.
(e) If there is traumatic bleeding, hemostasis can be (g) 15% KCl 10 mL + 5%G.S. 500 mL + Vitamin B6
achieved by local compression, and there is no need 100 mg + Vitamin C 2 g + Metoclopramide 10 mg, iv
to discontinue the anticoagulant. If an urgent surgery drip, q.i.d. Daily rehydration of fluid above 3000 mL.
is required, it may be done with intravenous injection 7. VAC treatment program for ovarian cancer.
of vitamin K1. (a) V (Vincristine): 5% G.S. 500 mL + vincristine
(f) In case of an elective surgery, first discontinue the 1–1.5 mg, once a week × 12 weeks.
medication for 2–3 days and if the prothrombin time (b) A (Actinomycin): 5%G.S. 500 mL + dactinomycin
returns to normal, the operation may be undertaken. 400 mg, iv drip × 5 days.
36–72 h later, the medication is resumed at an initial (c) C (Cyclophosphamide): cyclophosphamide 5–7 mg/
dose of 2.5 mg, and then discontinue the medication (kg • day) or 500 mg/day, into the pot, iv drip, ×
for 1 day. On the third day, a dose of 2.5–5 mg is 5 days.
administered and its dosage should be adjusted (d) Once a month for two consecutive years.
according to the prothrombin time. (e) If actinomycin is unavailable, amycin 500 mg may be
(g) If there is more vaginal bleeding, the patient can be used once a month for 2 consecutive years.
given intramuscular injection of oxytocin or symp- (f) Zofran 8 mg into a small pot is given daily prior to
tomatic treatment like D&C, and there is no need to infusion.
discontinue anticoagulants. If an emergency surgery 8. Hysterosalpingography with iodine oil
is needed and INR value is higher, injection of vita- (a) 76% meglumine diatrizoate 20 mL × 1.
min K1 antagonism may be given when necessary. (b) 76% meglumine diatrizoate 2 mL for test sensitivity
(h) In case of an elective surgery, warfarin should be dis- (for intravenous injection).
continued 5 days before surgery and an injection of 9. Bowel preparation with polyethylene glycol electrolytes
low molecular heparin is administered instead, such powder.
as subcutaneous injection of fraxiparine 1 mg/kg, (a) Ordinary bowel preparation in gynecology.
per 12 h, given and stopped on the day of surgery • Diet preparation.
(usage: For a patient with weight of less than 70 kg, –– On the day before surgery, taking soft food at
each injection 0.4 mL is given; for a patient with noon and liquid diet at night (such as lotus root
weight greater than 70 kg, each injection 0.6 mL is starch, various soups, but excluding food easy
given). The ratio of INR at operation is preferably to produce flatulence like beans, milk, sugar,
less than 2. and others). Two packs of polyethylene glycol
(i) If there is not much bleeding from the wound after electrolytes powder are taken around 4 p.m.
surgery, an injection of low molecular heparin is Fasting starts on the morning of surgery.
administered on the first day after operation (the –– If reactive hypoglycemia like dizziness, palpi-
usage is same as above). Three days later, warfarin tations, hunger, and others appear, please tell
(2.5 mg, q.i.d) is added. After combined use for the doctor and nurse (some fluid rehydration
3 days, the use of low molecular heparin is discontin- may be applied).
ued. Four items of coagulation tests are checked once • Oral whole-gut lavage fluid.
every 3–5 days. The dosage of anticoagulants is –– The preparation of the whole-gut lavage fluid:
adjusted according to INR value, and when its value 1 pack of polyethylene glycol electrolytes
becomes stable, the reexamination is conducted once powder is poured into the large pot (provided
by nursing department), and warm water is
added up to 1000 mL, then it is stirred so as to –– The patient should tell the nurse about the
dissolve completely. number of defecation and the texture of stool
–– How to take: Two packs of polyethylene glycol (such as formed stool, paste stool, loose stool,
electrolytes powder with a total volume of watery stool, and clear watery stool).
2000 mL are taken. 1000 mL fluid is taken –– After taking polyethylene glycol electrolytes
orally every hour until all the fluid is consumed powder or anal enema, the fluids inside the
completely or a clear watery stool is dis- intestinal tract should be emptied as far as
charged. During medication, the upper body possible.
should be maintained upright, and the patient (b) Cleaning the intestinal tract as preparation for gyne-
can also drink while going about and can do cologic surgery.
abdominal massage gently clockwise. The • Diet preparation.
fluid should be finished in approximately 2 h. –– On the day before surgery, liquid food with-
• Precautions. out residue is eaten at noon (such as por-
–– Some patients may develop abdominal disten- ridge, noodles, but excluding foods easy to
tion, abdominal pain, nausea, vomiting, and other produce flatulence like beans, dairy, sugar,
reactions after taking polyethylene glycol electro- and others) and fasting in the evening. Two
lytes powder. The patient with mild symptoms packs of polyethylene glycol electrolytes
may be relieved when slowing down the drinking powder are taken on an empty stomach
speed appropriately. If necessary or with severe around 11 a.m., and another two packs of
symptoms, tell your doctor and nurse in charge. polyethylene glycol electrolytes powder are
–– If you usually have dry stool, please take laxa- taken around 4 p.m. Fasting starts on the
tive ahead of time before taking polyethylene morning of surgery.
glycol electrolytes powder. –– If reactive hypoglycemia symptoms like dizzi-
–– Generally the patient will defecate within 1 h ness, palpitations, hunger, and others appear,
after taking the medicine. If it does not occur at please tell the doctor and nurse (Fluid rehydra-
3 h, the patient should tell the nurse in charge tion can be given). A companion can be with
and the intestinal tract should be cleaned com- the patient to observe any sign of hypoglyce-
bined with other ways. mia if she has diabetes.
• Oral whole-gut lavage fluid (as stated above).
Table-Appendix 1 Guideline of Preoperative bowel preparations for laparoscopic surgery

1. Laparoscopic examination or monitoring 2. Simple laparoscopic surgery:
Simple adnexal surgery, simple ovarian
cyst, small subserous myoma, estimated
adhesion-free surgery, and so on
The day Semi-liquid diet at noon, fasting in the evening, fasting and water deprivation on the Semi-liquid diet at noon, fasting in the
before morning of surgery evening, nil by mouth on the morning of
surgery Liquid paraffin 30 mL 4 p.m. p.o. surgery
Folium sennae 10 g is taken with water
Liquid paraffin 30 mL 4 p.m. p.o.
3. More complex laparoscopic surgery: 4. With severe pelvic adhesions and
LAVH, TLM, large ovarian cyst, with a history of open surgery, chocolate cyst with suspected bowel injury
suspected adhesions, suspected bowel injury during surgery
Ordinary surgery Complex surgery with possible bowel
injury
3 days Regular diet Liquid diet without residue
before Metronidazole 0.4 g t.i.d Gentamicin 80,000 u b.i.d
surgery Gentamicin 80,000 u b.i.d × 3 days Metronidazole 0.4 g b.i.d
Vit K1 10 mg im q.i.d or small
pot × 3 days
2 days Semi-liquid diet Semi-liquid diet Liquid diet without residue
before Folium sennae 10 g, taken with water for 50% MgSO4 30 mL
surgery 2 days
The day Full liquid diet on the morning and at Full liquid diet on the morning and at Fasting
before noon, and fasting on the evening; noon, and fasting on the evening; Cleansing the intestinal tract on the
surgery Nil by mouth on the morning of surgery; Nil by mouth on the morning of surgery, night before surgery and on the morning
Liquid paraffin 30 mL 4 p.m. p.o. Cleansing the intestinal tract at 3 p.m. of surgery
Fluid replacement 1500 mL(MG3 the day before surgery and at 6 a.m. on Rehydration 3000 mL
1000 mL + lactated Ringer’s solution the morning of surgery Replacement of potassium: 15%KCl
500 mL) Fluid replacement 2000 mL (MG3 10 mL
1000 mL + lactated Ringer’s solution Note: For the patient with poor
1000 mL) nutrition: Ensure 1 tin p.o.
Basic hospital diet
1. Semi-liquid diet: porridge, noodles, dumplings, steamed egg, tofu, etc. 4–5 times daily
2. Liquid diet: rice soup, sugar-free lotus root starch, gravy, vegetable juice, etc. 5–6 times daily
ppendix 2: A Practical Manual
A
of Hysteroscopic Surgery
acilities of Operating Room and Patient’s

F so as not to affect the laparoscopic procedure. Generally,
Body Position a slightly low head position is taken.
4. The distance between the height of distention medium
1. Operating room: An operating room should be spacious, and the patient’s pubic symphysis is from 100 cm to
and the operating table should be put in the center, at the 120 cm so as to maintain a certain intrauterine distention
head of which can be placed the anesthesia machine and pressure. If the automatic uterine distending pump is
monitors manipulated by the anesthetists. On one side of applied, the pressure can be adjusted to the mean pulse
the patient are placed a multi-layer cart or supplies boom pressure. When operation starts, if hypertrophic endome-
with TV monitor, video camera, recorder, fluid distending trium or large submucous myomas occupy the uterine
pump, and other equipment on it, and also placed instru- cavity, and narrowed septate uterus or intrauterine adhe-
ment tables and B-mode ultrasonography machine; on the sions restrict distention medium into the uterine cavity
other side are current generator and cold light source. leading to obscure vision, the intrauterine pressure can be
There are at least 3 sockets in the wall which are powerful elevated instantly, but only transiently.
enough to meet the demand of electricity for operation. 5. Be sure to open the inflow and outflow switch, and empty
2. Gynecologic operating table: It should have the following the gas out of fluid irrigation tube. When operation begins,
functions: switch on continuous perfusion system to irrigate and
(a) The patient’s position can be changed quickly with wash off intrauterine tissue fragments and blood.
the requirement of operation in order to meet the Sometimes, if there is larger blood clot blocking the sheath
objective need that the resecting time is restricted. and hindering the circulation of distention medium, the
(b) There should be enough space in the operating area hand piece and the scope or the inner sheath must be taken
so as to facilitate the resecting surgery smoothly. out and cleaned. After one has a clear vision of the uterine
(c) There should be a complete system of irrigation and cavity, then connect the cables and start the operation.
collection of distention medium so as to adapt to the 6. At present, the commonly used intrauterine electrosur-
massive requirement of fluid by resection surgery. gery is a monopolar circuit loop. Before switching on the
(d) It should have a wide variety of applications, on power for operation, remember to check the loop elec-
which any gynecological operation can be performed trode in the patient to ensure a complete current cycle. If
so that the operation can be immediately transferred nonelectrolyte liquid can be used as distending medium
to laparotomy in case of need. only, prepare some active electrodes for spare use before
3. Position: The patient is placed in a modified lithotomy each operation, in order that the active electrode is
position, that is, supporting the legs with the relaxed changed in time if tissue fragments adhere to the elec-
knees, the thigh at an angle of 45° to the horizontal line, trode. The replaced electrode can be reused after being
abduct legs to an extreme degree in order to increase the cleaned. The usual power is set at 80 W for electroresec-
available space. Compared with full lithotomy position, tion and 60 W for electrocoagulation, and may be regu-
this position is advantageous in small intra-abdominal lated according to intraoperative conditions. If a
pressure, no interference with breathing and easy access hysteroscopic plasma bipolar working element is applied,
to the tubal ostia. If laparoscopy is at the same time per- the power is set at 250–310 W for electroresection and
formed, make the thigh at 30° angle to the horizontal line 90 W for electrocoagulation.

450 Appendix 2: A Practical Manual of Hysteroscopic Surgery
Preoperative Preparations 2. For those who have completed endometrial pretreatment,

operation may also be performed during non-menstrual
1. Preparation on the day before operation. phase.
(a) Disinfection of hysteroscope and its instruments. 3. If there is an uncontrollable bleeding, emergency opera-
(b) Cervical dilator or laminaria tent is introduced into tion should be done.
cervix on the night before operation to soften and
dilate the cervix. When insertion is difficult, 100 mg Anesthesia
indomethacin can be used per rectally. Or misopros- Commonly, general intravenous anesthesia or continuous
tol 400 μg is placed into posterior fornix of the vagina epidural anesthesia is conducted.
2 h prior to the operation. Also phloroglucinol
(smooth muscle antispasmodic agent), 40–80 mg is Operating Procedures
given by intravenous drip 15 min prior to operation, 1. The patient is placed in lithotomy position on the operat-
which should be finished in 5 min. ing table, and the vulva and vagina are disinfected rou-
2. Preparation on operation day tinely with 0.25%–0.5% iodophor solution. If cervical
On the morning, the patient should have fasting and have dilatation rod is inserted, the assistant should wear sterile
a full bladder so as to facilitate ultrasonographic monitor- gloves and remove it from the vagina, which can avoid
ing during operation. fracture of cervical dilator by other methods and partial
3. The transparency and activity of the operating frame, retention in the uterine cavity. After placement of surgical
whether the connectors on current generator, cables, and drape sheets, the external orifice of urethra is disinfected
the electrode plate are loose or not should all be checked. and urinary catheter is inserted. An injection of distention
If there is malfunction with the equipment, it should be medium (5% glucose or 5% mannitol) is introduced into
repaired timely prior to operation. There should be a cer- the bladder to fill the bladder properly so as to push the
tain number of wire loops for spare use. bowel covering the uterine surface aside. The uterus is
clearly displayed with acoustic beam through the acoustic
window formed by the filling bladder. The amount of dis-
Transcervical Resection of Endometrium tension of the bladder varies from person to person. For
(TCRE) those who have no history of pelvic surgery, the upper
half of the uterine corpus needs to be shown. During hys-
teroscopy, the cervical forceps is used to pull the cervix
Indications downward and the uterine fundus is exposed, and this will
1. Persistent abnormal uterine bleeding, and malignant dis- not affect the surgeon’s operation due to the overfilling of
eases have been excluded. bladder. For those who have history of pelvic surgery, if
2. The uterus is enlarged to 8–9 weeks of gestation, and there are pelvic adhesions, when the cervical forceps is
uterine cavity is 10–12 cm in length. pulled downward, the mobile extent of the uterus will be
3. submucous myoma with 4–5 cm in diameter. small. Therefore, there should be slightly more bladder
4. No requirement for fertility. filling than those with no pelvic surgery, and it is enough
to expose the uterine fundus.
Contraindications 2. Then go on to disinfect the vagina and cervix, place the
1. Cervical scar and the cervix cannot be well dilated. vaginal speculum and clamp the cervical anterior lip with
2. Acute uterine flexion and the hysteroscope cannot reach cervical clamp, detect the depth of uterine cavity under
the uterine fundus. ultrasonography surveillance, and then dilate the internal
3. Acute stage of reproductive tract infection. cervical os gradually enough to insert the operative hys-
4. Acute period of heart, liver, and kidney failure. teroscope, usually 10–11 mm. Then, install light sources,
5. One has no good psychological capability to bear the fact irrigation tubing, cables (its surface is scrubbed with 75%
that this operation is to relieve symptoms rather than a ethanol), and manipulator control. If the cervical internal
radical cure. os is tight and difficult to dilate, the obturator can be
inserted with the sheath into the cervix so that its front
Timing of Operation end may further dilate cervical internal os. After entering
1. After menstruation, the endometrium is at its early pro- the uterine cavity, the obturator can be taken out, and then
liferative stage, which is the optimal time for introduce hysteroscope and manipulator control into the
operation. uterine cavity for operation.
Appendix 2: A Practical Manual of Hysteroscopic Surgery 451
3. If endometrium is found to be thick, suction aspiration better to be retained in the uterine cavity and be pushed at
can be first used. uterine fundus until the end of surgery.
4. The resection of endometrium must follow a certain pro- 7. The depth of the resection depends on the endometrial
cedure. First, use vertical wire loop electrode to cut the thickness, and the aim is to cut into the superficial myo-
portion of uterine fundus. This area is the hardest to metrium 2–3 mm underlying endometrium. This depth is
resect, but easy to perforate, therefore the operator must sufficient to remove the full layer of endometrium except
be very careful. The uterine fundus is easy to be covered for the extremely deep endometrium without cutting the
by the resected fragments, thus the vision is hindered. So, larger vessels. If endometrium has been pretreated previ-
some people prefer to use rollerball electrode to coagu- ously, generally it rarely requires cutting more than once
late the fundal endometrium and then use wire loop to do and can reach the desired depth. If endometrium is
with the rest parts. Some would like to use a wire loop thicker, electrocoagulation can be repeated following the
with an angle of oblique forward 10° to resect the uterine electric cutting, by which the efficacy can be improved.
fundus, and a wire loop with an angle of oblique back- There is no difficulty concomitant with resection of sub-
ward to resect the rest of the uterine cavity. During the mucous myoma <3 cm, and a larger myoma may also be
operation, one or two wire loop electrodes suitable for resected with necessary devices. After resection, the
management with the uterine fundus and uterine cornua electro-resectoscope is retrieved and the oval forceps or
should be prepared. Since the endometrium resected at curette is used to remove endometrial fragments, and a
two cornua appears to be fragmented, therefore the opera- small amount of endometrial fragments can be discharged
tor must be very careful not to push the wire loop too far spontaneously several days after operation. The endome-
into the myometrium. Especially after resecting the por- trial fragments are sent for histological examination.
tion of two cornua which is the thinnest, the operator 8. After the uterine cavity is made empty, the hystero-
must cut and shave shallow each time until all the endo- resectoscope is put back to check whether there is resid-
metrium is removed completely, which is at a less risk of ual endometrium or large bleeding points. The former
perforation than a deep cut. needs to be resected while the latter needs electrocoagu-
5. After management with the uterine fundus, the 90° wire lation with wire loop or rollerball electrode. The irriga-
loop is pushed out of sheath and extended to the distant tion system prompts an increase in the intrauterine
position. According to the requirements on the depth and pressure and intraoperative bleeding is rare. When uterine
length of resection, a parallel cutting is done from the dis- distention pressure drops, the bleeding points become
tal to the proximal. First the sheath is pulled back and evident. Unless there is a large amount of bleeding, there
anterograde resection is undertaken. Then the spring of is no need to waste time in electrocoagulation.
the cutting handle is loosened slowly. Only when the wire 9. The total resection includes the resection of total uterine
loop electrode is moved into the sheath and the foot pedal cavity and upper cervical canal. Partial resection is the
is released will the tissues be possibly resected completely. resection of full-layer endometrium in the upper 2/3 por-
For the beginners, the moveable distance of wire loop tion of uterine cavity. The left untreated endometrial edge
electrode is confined within 2.5 cm, and a systemic resec- is 1 cm in width, located above the isthmus of uterus. The
tion of endometrium is resected from 9 o’clock position in patients who undergo routine partial resection are afraid
a counterclockwise direction. First, resect endometrium of that the total resection may induce the cervical stenosis,
upper 1/3 portion of uterus, then resect middle 1/3 portion and if there is functional endometrium in the uterine cav-
of uterus. If total endometrial resection is to be done, ity, secondary intrauterine hematometra may occur. The
resect the lower 1/3 portion of uterus until the cervical hematocele is more often at the uterine fundus clinically
canal. If the operator is skilled and proficient, he can rather than on the isthmus, therefore, it is unnecessary to
increase the cutting distance through moving the hystero- undertake partial resection unless there is still desire for
resectoscope from the uterine fundus to the uterine isth- menstruation after operation.
mus, and take out the resected tissue strips immediately.
6. The resection of endometrium in uterine walls is prefer- I ntraoperative Ultrasonography Monitoring
ably to begin with the posterior wall because the resected and Guidance
debris is likely to gather and cover in the posterior wall. 1. The operator may observe the probe entering the uterine
Although the tissue fragments can be clamped out piece cavity, determine the direction of the probe reaching the
by piece from the cavity, the distention fluid will flow out fundus and guide the hysteroscope to be placed at the cer-
from the cervical os each time. Each dilation and collapse vical internal os. The distention medium injected into the
of uterine cavity may cause uterine bleeding, thus hinder- uterine cavity and the filling bladder form acoustic win-
ing the hysteroscopic view. So the tissue fragments are dows for double contrast.
2. From the beginning of surgery to the end, the two- 4. Transcervical resection of endometrium may produce cer-
dimensional double-contrast ultrasonographic imaging is tain contraceptive effects with a low failure rate like all other
performed in continuous monitoring of surgical process. contraceptive measures, so if there is abnormal condition,
The following contents should be included in observa- please come quickly to the hospital for a diagnosis. However,
tion. (a) Changes in the thickness of uterine wall and the this does not belong to the scope of family planning.
location of resectoscope should be observed in order to 5. Sexual intercourse should be banned for 2 months after
prevent uterine perforation. (b) Signs in the changes of operation.
the echo under the effect of electric heat on the inner 6. The patients who have adenomyosis diagnosed postop-
lining of the uterus and the muscle wall should be
eratively require medication therapy, such as gestrinone,
observed so as to determine the electric cutting depth, danazol, and GnRH-analogs for 3 months. After adminis-
extent, and intramural lesions as well. (c) The location tration of danazol and gestrinone for 1 month, the patients
and size of the intrauterine lesions and the relationship should take liver function tests. If there is abnormality,
between the pathological changes in the uterine muscle the medication is discontinued.
wall and the uterine cavity should be determined and the
resection of intrauterine and intramural lesions should be
monitored. (d) Whether there is previous uterine malfor- Transcervical Resection of Myoma
mation and old injury in the uterine muscle wall which (TCRM)
are difficult to diagnose should be explored before sur-
gery. (e) Observation of uterus and monitoring whether
there is distention medium flowing via the fallopian tubal Indications
ostia into abdominal cavity or not and its volume should TCRM procedure is suitable for symptomatic submucous
be conducted. myoma, inward-protruding intramural myomas, and cervical
3. The resected uterine lining may dehydrate and shrink due myoma.
to heat produced by the high-frequency thermal effect of 1. Menorrhagia or abnormal bleeding.
the wire loop during TCRE procedure, and the strong lin- 2. The size of the uterus is generally limited to 10 weeks of
ear echo in the inner lining of the uterus turns into strong gestation and the length of uterine cavity is limited to
echogenic band of 3–4 mm in breadth. When cutting 12 cm.
reaches myometrium, the strong echogenic band may 3. The size of submucosal or inward-protruding intramural
fade away after 15–40 min of resection. In case of patients myoma is generally limited to less than 5 cm.
with DUB, when the cutting depth is confined to the 4. No cancerous changes in uterus.
mucosal layer, the strong echogenic band formed may More than one procedure may be required to complete the
disappear rapidly. During operation, the important indi- removal of submucous myomas deeply embedded into myo-
cation for prevention of missed resection is whether the metrial layer and inward-protruding intramural myomas. As
strong echogenic light band is intact or not. The duration to the submucosal myomas which prolapse into the vagina,
of the strong echogenic light band is the ultrasonic indi- its size or thickness of the pedicle is not restricted.
cation suggestive of the cutting depth. The location of
resectoscope is closely monitored so as to prevent the Contraindications
wire loop from leaning tight against or penetrating the 1. Cervical scar and the cervix cannot be fully dilated.
uterine wall. When the outer edge of the strong echogenic 2. Acute uterine flexion and the hysteroscope cannot reach
band reaches the deep myometrium, it suggests that the the uterine fundus.
operator should stop the local cutting, which may prevent 3. Acute stage of reproductive tract infection.
uterine perforation effectively. 4. Acute period of heart, liver, and kidney failure.
5. Patients who have no good psychological capability to
Postoperative Precautions bear the fact that this procedure may relieve symptoms of
1. A small amount of bleeding and discharge are normal hemorrhage but recurrent myomas after operation.
within 2 months after operation. If there is too much
bleeding and discharge, a follow-up is needed. Preoperative Preparations
2. If there is bleeding in patients at the third month after 1. Preoperative medication pretreatment (if there is larger
resection of endometrium, it is menstrual blood. myoma and difficult operation in patients) is adminis-
3. Outpatient reexamination should be conducted in the first tered with GnRH-a, once every 28 days for a consecutive
and third month after operation, and re-check should be 3–6 months. The surgery is performed within 3–6 weeks
followed once every half a year thereafter. after the last medication.
2. If myoma is not prolapsed out of the cervical canal, cervi- are excised. With this repeat action, the tumor is cut
cal ripening is conducted on the night before surgery. piece by piece, and the size of the myoma is shrunk, thus
Indomethacin 100 mg can be used per rectally and 30 min dissecting the myoma completely. Alternatively, the for-
later the uterine cervical dilator or laminaria tent is ceps are used to clamp the myoma and screw out by
inserted into the cervix. twisting. The myoma is removed completely by repeat
3. On the morning of surgery, the patient should be fasted cutting and clamping of the myoma or clamped out by
and ace a full bladder so as to facilitate ultrasonographic cutting off the tumor pedicle. Intraoperative administra-
intraoperative monitoring. tion of oxytocin via intravenous injection and surgical
operation may increase the protruding degree of submu-
Timing of Operation cous myoma into uterine cavity, and even some intramu-
The ideal time for operation is at the first half of menstrual ral myomas as well, which may be transformed into
period. If there is excessive bleeding, the operation must be submucous myomas and can be removed.
done even in the secretary phase. If there is uncontrollable 5. As to pediculated submucous myomas, the tumor is
bleeding, an emergency surgery may be performed. made smaller by cutting or its pedicle is cut off and then
is removed with forceps. If there is larger myoma or
Anesthesia there is no way to clamp out the myoma because of its
Continuous epidural anesthesia is generally administered. smooth surface, the tumor needs cutting and its size is to
be shrunk. It is better to cut grooves in the tumor so as to
Operating Procedures facilitate the clamping.
1. The patient is placed in lithotomy position, and the assis- 6. As to sessile submucosal myoma, the wire loop elec-
tant should remove the cervical dilator from the vagina trode of 9 mm hystero-resectoscope is used to cut gradu-
with sterile gloves. The patient’s vulva and vagina are ally along the tunica at the bottom of the myoma under
regularly disinfected with 0.25%–5% iodophor, and sur- intensive monitoring of the ultrasonography. The distal
gical drape sheets are placed under the buttocks. The end of the telescope may be used to press myomas so as
negative plates are attached to the patient’s buttocks or to blunt dissect the muscular layer. When the resection
thighs (with rich muscles), turn on the power switch and has been conducted to a certain degree, myomas may be
set at 80 W for electric cutting and 60 W for clamped with myoma forceps, twisted and pulled while
electrocoagulation. viewing the ultrasonic image to separate the myomas
2. After disinfecting the hands, the operator puts on sterile from the wall of uterine cavity. Clamping and cutting are
gloves, insert the vaginal speculum, disinfect the vagina repeated until the total removal of myomas. As to the
again, clamp the anterior lip of cervix with the cervical myoma with protruding degree <20%, when resection
clamp, disinfect the cervical canal, and dilate the cervix starts, the myoma begins to protrude into the uterine
to 11–12 mm. cavity, so a complete resection is possible. If not com-
3. Install the irrigation tubing, cables, light source and pletely resected, use a 9 mm hystero-resectoscope to
adapter and disinfect with 75% ethanol twice, and empty resect the myoma in uterine cavity and the residual
the gas out of the irrigation tubing, install them in turn myoma in the myometrium more than 5 mm; after 2 to
onto the manipulator’s handle. Adjust the camera focus, 3 months of operation, conduct reexamination by hyster-
color, and definition before inserting it into the uterine oscopy, and then perform TCRM again to resect the
cavity. Check the negative plate, open the inflow and myoma protruding into the uterine cavity completely.
outflow switch, then insert the endoscope into the uter- 7. As to multiple submucous and intramural myomas, it
ine cavity. should be resected as much as possible at a time. When
4. To begin with, diagnostic hysteroscopy is performed. By the operation ends, IUD should be placed in the uterine
ultrasonography, the location of intrauterine myoma and cavity, and taken out 2 months later.
the status of pedicles are examined carefully. Then, the 8. Cervical myomas are all coated. As to the cervical myo-
surgery is performed according to the types of the myomas prolapsed from the cervical canal, wire loop elec-
mas. First, the wire loop electrode and rollerball electrode can be used to cut off the pedicle and remove it
trode are used to coagulate the large vessels in the completely or cut open the capsule and screw it out. As
surface of myoma and blood vessels in the tumor pedi- to the myomas embedded in the cervical tissues, as long
cle, which may reduce intraoperative bleeding. The wire as its outline is made clear, the wire loop electrode is
loop electrode is placed at the distal side and step on the used to cut from the thinnest part of the embedded tis-
foot pedal. When the hands have a sense of cutting, sues, when cutting reaches the myoma, the incision can
move the cutting handle or spring and then start resec- be appropriately extended, and the myoma can be
tion of tissues. When the wire loop electrode is moved stripped out from the capsule completely. After the
into the sheath and the foot pedal is released, the tissues removal of myomas, generally the tumor bed does not
bleed. If the tumor bed is larger or the outline of cervix Contraindications

is not integrated, absorbable catgut can be used for 1. Cervical scar and the cervix cannot be dilated fully.
suture. As to sessile submucous myoma in the cervical 2. Acute uterine flexion and the hysteroscope cannot gain an
canal, since the cervical canal wall has become very access into the uterine fundus.
thin, it is extremely easy to cause perforation. 3. Acute stage of reproductive tract infection.
9. As to the large fibroid of more than 6 cm in diameter, 4. Acute period of heart, liver, and kidney failure.
preoperative treatment with GnRH-analogs should be
administered. Preoperative Preparation
10. It should be noted that the operative time should be limited 1. Cervical ripening is conducted on the night before sur-
within 1 h and absorption volume of irrigation fluid should gery. Indomethacin 100 mg can be used per rectally and
be limited in 2000 mL so as to avoid TURP syndrome. 30 min later the uterine cervical dilator or laminaria is
11. After operation, the uterine cavity is inspected, and inserted into the cervix.
hemostasis is achieved by electrocoagulation of the 2. On the morning of surgery, the patient should be fasted
bleeding points. If there is more hemorrhage, a balloon and have a full bladder so as to facilitate B ultrasono-
catheter may be placed into the uterine cavity to achieve graphic intraoperative monitoring.
hemostasis by compression, and saline of 15–40 mL is
introduced into the balloon, and the balloon is taken out Timing of Operation
after 4–6 h. Meanwhile, uterine contraction agents and 1. After menstruation, the endometrium is at its proliferative
hemostatic agents can be used. stage, which is the optimal time for operation.
12. The specimens are measured in weight and sent for his- 2. For those who have had endometrial pretreatment, opera-
tological examination. tion may also be performed during non-menstrual phase.
3. If there is an uncontrollable bleeding, emergency opera-
Postoperative Management tion should be done.
1. Antibiotics is administered via intravenous dripping so as
to prevent infection. Anesthesia
2. Observation of the vital signs. The time for TCRP procedure is short, so intravenous anes-
3. Observation of hemorrhage. If there is more bleeding, thesia can be administered. If the expected operative time is
oxytocin and (or) hemostasis with 5% glucose solution longer, continuous epidural anesthesia can be given.
500 mL, vitamin C 3 g, dicynone 3 g, and pamba 0.3 g
can be administered by intravenous route. If there is acute Operating Procedures
active bleeding, electrocoagulation hemostasis should be 1. The patient is placed in lithotomy position, and the
applied again under hysteroscope. assistant should remove the cervical dilator from the
4. After 6 h of fasting, regular diets are administered. vagina. The patient’s vulva and vagina are regularly
5. Attention should be paid to the electrolyte and acid-base disinfected with 0.25%–5% iodophor, and surgical
balance. drape sheets are placed under the buttocks. The nega-
tive plates are attached to the patient’s buttocks or
Postoperative Precautions thighs (with rich muscles), turn on the power switch
1. It is normal that there is a small amount of bleeding and and adjust it at 80 W for electric cutting and 60 W for
discharges in patients within 2 months after the surgery. electrocoagulation.
2. Sexual intercourse should be banned for two months. 2. After disinfecting the hands, the operator puts on sterile
3. Regular reexamination should be done in an outpatient gloves, inserts the vaginal speculum, disinfects the vagina
setting. again, clamps the anterior lip of cervix with the cervical
pliers, disinfects the cervical canal, and dilates the cervix
to 9–10 mm so that the operative hysteroscope can be
ranscervical Resection of Endometrial
T inserted.
Polyp (TCRP) 3. Install the irrigation tubing, cables, light source, and
adapter and disinfect with 75% ethanol twice, and empty
the gas out of the irrigation tubing, install them in turn onto
Indications the manipulator’s handle. Adjust the camera focus, color,
This procedure is suitable for the removal of symptomatic and definition before inserting it into the uterine cavity.
uterine endometrial polyps, with the exception of malignant Check the negative plate, open the inflow and outflow
change of polyps. switch, then insert the endoscope into the uterine cavity.
4. First, a diagnostic hysteroscopy is performed to deter- ranscervical Resection of Uterine Septum

T
mine the number, size, and pedicle location of the polyp. (TCRS)
5. The wire loop electrode is extended to the distal side of
the basal pedicle of the polyp to be resected and step on
the foot pedal. When the hands have a sense of cutting, Indications
move the cutting handle or spring and then start resection The procedure is suitable for symptomatic complete and par-
of tissues. When the wire loop electrode is moved into the tial septate uterus.
sheath and the foot pedal is released, the tissues are
excised. Make sure that the pedicle is removed totally lest Preoperative Preparations
it may recur later. The operation should be performed within 3–7 days after
6. As to multiple polyps, resection of part of the polyp may menstruation. The surgery is usually performed under lapa-
also be done. Then the negative pressure suction aspirator roscopic diagnosis and monitoring. Liquid paraffin 30 mL is
can be used to suck out the endometrium and polyps. If taken orally at 4 p.m., semi-liquid food is allowed for dinner
the endometrium lining the surface of polyps is sucked and at 7 p.m., the cervical dilator is inserted into the cervix
out, there will be only the interstitial tissue of the polyps on the day before surgery. On the morning of surgery, the
left with its size and diameter explicitly shrunk. With the patient should be fasting and antibiotics are administered for
inflow of irrigation fluid, its resection is made easy. prevention on the day of surgery.
7. If there are larger blood vessels on the surface of the tis-
sues to be excised, vascular electrocoagulation should be Operating Procedures
done before cutting tissues. 1. After a successful general anesthesia, the patient is placed
8. After operation, the uterine cavity is inspected, and hemo- in lithotomy position, and regular disinfection of the lapa-
stasis is achieved by electrocoagulation of the bleeding roscopic operating field is performed. The cervical dilator
points. If there is more hemorrhage, a balloon catheter is removed from the vagina, and the patient’s vulva and
may be placed into the uterine cavity to achieve hemosta- vagina are disinfected with 0.25%–5% iodophor.
sis by compression, and antibiotics may be administered, 2. The negative plates are attached to the patient’s buttocks
and the intrauterine residues are to be emptied in combi- or thighs (with rich muscles), turn on the electric knife
nation with the administration of uterine contraction switch and adjust laparoscopy at a power of 30 W for
agents and hemostatic agents. The balloon catheter should electric cutting and electrocoagulation, and the hysteros-
be taken out 4–6 h later. copy is adjusted at a power of 80 W for electric cutting
9. The specimens are measured in weight and sent for and 60 W for electrocoagulation.
examination. 3. After placement of surgical drapes and sheets, diagnostic
laparoscopy is performed first to obtain information about
Postoperative Management the location and size of the uterus and the concave of uter-
1. Antibiotics is administered via intravenous route so as to ine fundus and exclude the condition of didelphic uterus,
prevent infection. bicornuate uterus, unicornuate uterus, and rudimentary
2. Observation of the vital signs. horns. If it is didelphic uterus, bicornuate uterus, unicor-
3. Observation of hemorrhage. If there is more bleeding, nuate uterus, and rudimentary horns, the hysteroscopic
oxytocin and (or) hemostasis with 5% glucose solution surgery is canceled.
500 mL, vitamin C 3 g, dicynone 3 g, and pamba 0.3 g 4. Under ultrasonography monitoring, a proper volume of
can be administered by intravenous drip. If there is acute fluid is introduced into the bladder so as to obtain a clear
active bleeding, electrocoagulation hemostasis should be image of uterus. The surface of irrigation fluid catheter,
applied again under hysteroscope. camera, and cable is scrubbed with 75% ethanol twice by
4. After 6 h of fasting, regular foods are administered. the assistant, and then they are installed with the manipu-
5. Attention should be paid to the electrolyte and acid-base lator’s handle.
balance. 5. When resecting incomplete uterine septum, first, the
shape and location of septum is observed. When endome-
Postoperative Precautions trium is thicker, leading to an obscure vision, suction
1. It is normal that there is a small amount of bleeding and aspiration can be first done to make the endometrium
discharges in patients after 2 months of surgery. thinner. The wire loop electrode is used to cut the septum.
2. Sexual intercourse should be banned for 2 months. When cutting, the wire loop electrode is placed on one
3. Regular reexamination should be done in an outpatient side of septum, and under ultrasonography monitoring a
setting. transverse cutting towards the opposite side is carried out,
and then a backward cutting from the opposite side is 9. When the operation comes to an end, the objective lens is
done. Attention should be paid to the penetrating depth, retrieved to the internal os, and symmetry of uterus is
the direction of the electrode, and the left-right equivalent observed. Then IUD is placed.
cutting. The operator should be watchful on the symme-
try of the uterine cavity and try to avoid the deeper cutting Postoperative Precautions
of one side, leading to the deformation of the uterus. 1. A slight lower abdominal pain may develop 1–3 days
When cutting reaches the base of septum, much attention after operation. A two-week rest and prophylactic use of
should be paid to avoidance of deep cutting and injury to antibiotics should be prescribed.
the uterine fundus. If necessary, the needle electrode is 2. The IUD placed in the uterine cavity should be removed
used to incise the junction site between the septum and 2 months after operation, and at the same time diagnostic
anterior-posterior uterine wall so as to restore the normal hysteroscopy is performed so as to obtain information
uterine cavity maximally. If there is bleeding, an optional about the uterine cavity. If necessary, a supplementary
electrocoagulation can be performed. cutting of the residual septum is undertaken.
6. As to resection of complete septate uterus, a 4 mm Hegar 3. Sexual intercourse is banned within 8 weeks after
dilator or a balloon is placed in one side of uterine cavity, operation.
and the septum from the upper portion of internal orifice 4. Hormone therapy is administered for three months after
of uterine cavity opposite to the Hegar uterine dilator or operation.
the balloon is cut, then the uterine dilator or the balloon is
taken out and the surgery is continued. The subsequent
procedures are the same as resection of subseptate uterus. Transcervical Resection of Adhesions (TCRA)
7. As to the resection of double cervix concomitant with
septate uterus, the surgical method is basically the same
as hysteroscopic resection of the complete uterine sep- Indications
tum. The surgery does not destroy the structure of double This procedure is applicable to the symptomatic patients
cervix, and attention should be paid to retention of tissues with intrauterine adhesion.
0.5–1.0 cm above the internal orifice of uterus.
8. Mechanical resection with scissors under hysteroscope is Preoperative Preparations
undertaken and the irrigating fluid may contain electro- The operation should be performed within 3–7 days after
lyte. Hysteroscopic scissors can be classified into soft, menstruation. The operation on patients with severe adhe-
semi-rigid, and rigid scissors. The soft scissors are not sions should be performed under laparoscopic monitoring.
easy to manage, so the semi-rigid scissors are most com- Liquid paraffin 30 mL is taken orally at 4 p.m., semi-liquid
monly used, which can divide the tissues directly, an food is allowed for dinner, and at 7 p.m., the cervical dilator
accurate cutting in the midline of septum and fibrosis site is inserted into the cervix on the day before surgery. If there
without the blood vessels should be started. Uterine myo- is difficulty in inserting cervical dilator, a fine catheter or
metrial vessels run from the uterine posterior-anterior laminaria is used to soften the cervix. On the morning of
wall into the septate tissues, the posterior and anterior surgery, the patient should be fasted and antibiotics are
wall of uterus should be avoided so as to prevent unneces- administered for prevention of infection on the day of
sary bleeding. The cutting should start from one side, and surgery.
cut gradually towards the opposite side, and cut off a
small piece each time. Once the fallopian tube ostia are Operating Procedures
seen, the cutting should be shallow. The operator should 1. After a successful general anesthesia under laparoscopic
watch carefully the small blood vessels from the myome- monitoring, the patient is placed in lithotomy position,
trial layer to avoid penetrating uterine myometrium. After and regular disinfection of the laparoscopic operating
resection of septa, the operator should observe the uterine field is performed. The cervical dilator is removed from
fundus under hysteroscope before the exit of the equip- the vagina, and the patient’s vulva and vagina are disin-
ment and decrease the intrauterine pressure to observe fected with 0.25%–5% iodophor.
whether there is obvious bleeding. If there is arterial 2. The negative plates are attached to the patient’s buttocks
bleeding, selective electrocoagulation can be carried out. or thighs (with rich muscles), turn on the power switch
The wide and large septum may affect the hystero- and set at a power of 30 W for electric cutting and elec-
resectoscopic operation and make the resection of septum trocoagulation, and the hysteroscopy is adjusted at a
difficult, the mechanical resection by microscissors or power of 80 W for electric cutting and 60 W for
division by laser optical fiber can be implemented. electrocoagulation.
3. After placement of surgical drapes and sheets, diagnostic to expand the uterine cavity. In case of total uterine cavity
laparoscopy is performed first to obtain information about occlusion, a division of the adhesions begins from the
the location and size of the uterus. If there is pelvic adhesion, internal cervical os until a new cavity is created and then
laparoscopic adhesiolysis is performed simultaneously. the cornua are opened. The continuous thicker adhesive
4. Under ultrasonography monitoring, a proper volume of tissues are not easy to divide and resect, a sharp biopsy
fluid is introduced into the bladder by the operator so as forceps may be used to open the uterine cavity step by
to obtain a clear image of uterus. The surface of irrigation step and make it symmetrical. If there is extensive adhe-
tubing, camera, and cable is scrubbed with 75% ethanol sion, the operator should be aware of the occurrence of
twice by the assistant, and then they are installed with the the perforation of uterus. At the end of surgery, diluted
manipulator’s handle. methylene blue solution is injected through the cervix for
5. Resection with hystero-resectoscope. First the shape and detection of tubal patency.
location of adhesions is observed. The filmy, loose adhe- 9. After operation, an IUD is placed into the uterine cavity.
sions can be divided by pushing with the tip of diagnostic
hysteroscope and there is not necessarily a need to dilate Postoperative Precautions
the cervix, which is generally applicable to fresh adhesion 1. A slight lower abdominal pain may develop 1–3 days
or old adhesions at cervical internal os. The old and com- after operation. A 2-week rest and prophylactic use of
plex adhesions found in the uterine fundus and bilateral antibiotics should be prescribed.
walls of the uterine cavity require removal with microscis- 2. The IUD placed in the uterine cavity should be removed
sors and wire loop electrode. As for horizontal or longitu- 2 months after operation, and at the same time diagnostic
dinal adhesive zone in a basically normal uterine cavity, the hysteroscopy is performed so as to obtain information
wire loop electrode may be used to remove the adhesions about the uterine cavity. If necessary, a second surgery
under ultrasonography monitoring. If necessary, retrograde should be performed.
resection of adhesive zone can be performed so as to restore 3. Sexual intercourse is banned for 8 weeks after operation.
the normal morphology of uterine cavity. In case of total 4. Hormone therapy is administered for three months after
uterine cavity occlusion or severe deformity of uterine cav- operation.
ity, a dissection of the adhesions should begin from the
internal cervical os until a new cavity is created. The aim of
surgery is to restore the normal morphology of uterine cav- ranscervical Removal of Uterine Foreign
T
ity maximally. The needle electrode is first used to incise Body (TCRF)
the uterine cavity, and under ultrasonography monitoring,
a 7 mm or 8 mm resectoscope is properly inserted to excise The common intrauterine foreign bodies include IUD, tro-
the adhesive tissues antegrade or retrograde, and the resec- phoblastic remnants, fetal bone and retained suture strings.
tion extends gradually in the uterine cavity till the uterine
fundus, and then the cornua. The bent-forward wire loop Removal of IUD
electrode may also be used to divide directly or excise
adhesions. If there is bleeding, an optional electrocoagula- Indications
tion may be performed. If there are extensive adhesions, Under the following conditions, the removal of IUD is
the operator should be alert to the perforation of uterus. needed with an aid of hysteroscope or ultrasonography
When the operation comes to an end, the objective lens is intervention:
retrieved to the internal orifice of uterus, and symmetry of 1. IUD with broken tail string, with stenosis or adhesion in
uterus is observed. And then an IUD is placed. uterine cervix and uterine cavity.
6. For the patients with stenosis of uterine cavity and amen- 2. When blind removal is difficult and IUD embedment is
orrhea due to scarred uterine walls resulting from intra- suspected, and only parts of IUD are taken out or frag-
uterine adhesions, the needle electrode is used to cut 4 to ments of IUDs still remain within the uterus.
5 strips along the long axis of the uterus to expand the 3. When reversible fallopian tube contraceptive device is
uterine cavity, and postoperatively the hormone therapy is deeply embedded in uterine cornua or its fragments are
administered to resume their menstrual cycle. still retained.
7. Under laparoscopic monitoring, the methylene blue solu- 4. When the women are at menopause (the longer duration
tion can be injected into the uterine cavity to do a test on of menopause, the more serious the atrophy of reproduc-
the fallopian tube patency. tive organ), the removal of IUD will be much more diffi-
8. The bendable semi-rigid or rigid scissors may be used to cult and prone to infection.
divide the adhesions from the center of the uterine cavity
Methods removed with the wire loop electrode of hysteroscope. The

1. The therapeutic hysteroscope, which is equipped with fresh residual fetal bones are easy to be taken out by hyster-
alligator forceps or grasping forceps, can be used to oscopy. The embedded fetal bones in the myometrium may
clamp foreign bodies under direct vision. If it is not pow- not be removed completely. Patients who failed to com-
erful enough, or if there is embedment, a hysteroscopic pletely remove the embedded fetal bones may conceive after
resectoscope needs to be replaced. The open type of operation, hence the removal of embedded fetal bones should
semi-wire loop can be put onto the stainless steel ring to not be roughly so as to avoid uterine perforation when
hook it out. clamping.
2. If an IUD is imbedded in the uterine wall or migrates
through the fibroids or is wrapping around the fibroids, emoval of Remaining Sutures
R
the wire loop electrode can be used to incise the myome- When the non-absorbable sutures were used at cesarean sec-
trium of the uterine wall around the embedded IUD or the tion or resection of uterine corpus, the residual thread or
fibroid is resected to remove IUD or to clamp out IUD thread node may be seen at the internal cervical os during
under ultrasonographic positioning. diagnostic hysteroscopy, and this foreign body may cause
3. If the IUD is embedded deep, laparoscopic examination endometrial bleeding or inflammation. The residual thread or
should be performed simultaneously to determine thread node may be pulled out by alligator forceps or
whether the IUD has passed through the uterine serosal removed by wire loop electrode under hysteroscope.
layer or not.
4. The spring and tail string of the reversible fallopian tube Monitoring of TCRF
contraceptive device are often embedded in tubal ostia At the removal of foreign bodies, precise positioning is
and uterine horns. Once the tail string is broken, the IUD required and uterine perforation should be avoided, so the
will be extremely difficult to remove. In such circum- surgery should be performed under ultrasonography and (or)
stances, the 21Fr operative hysteroscope and a closed laparoscopic monitoring.
electrode can be used to plough deep into the uterine cor- 1. Transabdominal ultrasonography monitoring: The double
nua and take it out. Alternatively a hook or a long curved or triple contrast transabdominal ultrasonography moni-
hemostat is placed in its side and it is hooked out or pulled toring is employed, which may have a guiding effect on
out under direct vision of resectoscope. the uterine probe, uterine dilator and the insertion of hys-
teroscope and avoid the occurrence of uterine perforation.
Removal of the Residual Trophoblastic Remnants Ultrasonography intervention can suggest the location,
The residual remnants of missed abortion, incomplete abor- size, and number of intrauterine foreign bodies, espe-
tion, adherent placenta, and placenta accreta in the uterine cially can locate the foreign bodies embedded in the uter-
cavity can cause intrauterine adhesions, amenorrhea, or ine wall, help to learn about its embedded depth, and
irregular bleeding. By D&C, the residual trophoblastic rem- decide on the ways to remove by resection, incision, or
nants may not be removed completely or may not be detected clamping of the foreign bodies; and it may detect the fetal
due to adhesions. The trophoblastic remnants confirmed by bones, small IUD fragments and broken hook buried in
hysteroscopy and fixed biopsy may be scraped or excised the endometrial layer or the myometrium, which cannot
with wire loop electrode under ultrasonography monitoring. be revealed by hysteroscopy or laparoscopy. At the time
The excised tissues may be sent for pathologic examination. of surgery, ultrasonography can guide the intrauterine
In the management of the residual trophoblastic remnants, hysteroscopic operation with wire loop. After resection
this procedure is characterized by easy operation and short with the wire loop electrode, its basal layer may dehy-
operating time, accurate location, and can remove the resid- drate due to heat, forming strong echo, which can guide
ual trophoblastic remnants completely, and obviously supe- the direction of the resection of cervix and intrauterine
rior to conventional D&C. adhesions, suggest and guide the cutting depth and assess
whether the embedded foreign bodies have been removed
Removal of Residual Fetal Bone completely or not. During the removal of residual fetal
The retention of fetal bone after abortion is a rare complica- bone or metal IUD fragments, since the fetal bones and
tion. Fetal bone remnants may sometimes occur in a late- metal fragments all have strong echo, ultrasonography
term induced abortion, and may often cause abnormal uterine cannot distinguish easily the strong echo formed by elec-
bleeding and infertility. The retained fetal bones sometimes troresection or by residual fetal bone and metal fragments
take up most of the uterine cavity. Strong intrauterine echo because of its resolution, and this is its weakness.
may be identified by ultrasonography and the retained fetal Ultrasonography intervention is non-invasive, inexpen-
bones may be observed directly under hysteroscope. Under sive, convenient, and is the most commonly used and
transabdominal ultrasonography guidance, the fetal bone is effective way in monitoring hysteroscopic surgery.
2. Laparoscopic monitoring: By laparoscopy the changes in Transcervical Resection of Cervix (TCRC)

the uterine surface can be directly observed. If the uterine
wall is seen to be translucent or the surface of serosa is
blistery, it indicates that the uterine perforation is immi- Preoperative Preparations
nent. Once uterine perforation occurs, the detection of 1. TCRC procedure should be performed within 3 to 7 days
wound, timely electrocoagulation and repairing of the after menstruation. On the morning of surgery, the patient
uterine wound by suturing can be performed by laparos- should be fasting.
copy, which cannot be accomplished by ultrasonography. 2. If cervicitis is at the stage of acute inflammation, the
Compared with ultrasonography, laparoscopic monitor- drugs (such as policresulen vaginal suppositories, confort
ing cannot indicate the conditions of uterine cavity, and pessaries) should be generally applied locally for
cannot guide the intrauterine operation, and cannot dis- 2–4 weeks, and surgery can be performed after the con-
play intraoperative changes in the uterine wall thickness, trol of acute inflammation.
so it must be applied in combination with hysteroscopy.
Laparoscopy is invasive and expensive. After all, there Operating Procedures
are rare cases of uterine perforation following TCRF, 1. The patient is placed in lithotomy position, and the
therefore, the patients who have higher risk factors for patient’s vulva and vagina are disinfected regularly with
uterine perforation may choose laparoscopic monitoring. 0.25%–5% iodophor. The surgical drapes are placed. The
3. Laparoscopic ultrasonography monitoring: Laparoscopic negative plates are attached to the patient’s buttocks or
ultrasonography (LUS) is higher in resolution than ultra- thighs (with rich muscles), the power switch is turned on
sonography. Its operative method is to first establish a and set at a power of 60 W for electric cutting and 40 W
pneumoperitoneum, then introduce a laparoscope, instill for electrocoagulation.
saline 200 to 300 mL into the pelvic cavity, and then the 2. The surface of irrigation tubing, camera, and cable is
laparoscopic ultrasonography probe (Sharplan probe scrubbed with 75% ethanol twice, and then they are
scanning range 180°, frequency of 8 mHz, 10 mm in installed with the manipulator’s handle.
diameter, probing depth of up to 6 cm) is introduced 3. The uterine cervical canal is disinfected with iodophor
under direct vision of laparoscopy via the cannula beneath cotton stick, the cervical lesion is examined, and the
the umbilicus or lateral side of lower abdomen into the range of resection is decided in combination with the pre-
abdominal cavity, allowing for a free scanning of uterus. vious results of CCT or TCT and cervical biopsy. For the
The laparoscopic imaging and ultrasonography imaging patients with cervical intraepithelial neoplasia (CIN), cer-
are displayed on a monitor via a mixer, which is helpful vical smear with 2.5% iodine tincture is done to judge the
to accurate understanding of uterine morphology, size, risk of cervical lesions. The resected tissues and other tis-
and identification of the lesions and the cutting range. For sues are separately examined pathologically. If necessary,
TCRF, laparoscopic ultrasonography can accurately several biopsy positions are recorded.
locate in patients the small lesions, detect or rule out inva- 4. Generally, the extent of resection is 1 mm more than the
sive intramural lesions and foreign bodies embedded in normal tissues, and the ideal cutting depth is 7 mm. If
the myometrial layer, and can also avoid the influence of coexisting with cervical canal polypoid or polyps,
intestinal gas. It can view the appearance of uterus via resection should be done under direct vision of hystero-
laparoscope, but also can guide the intrauterine operation scope. In case of CIN2 and CIN3 lesions less than
via laparoscopic ultrasonography. Laparoscopic ultraso- 2.5 cm in diameter, a cold knife conization should be
nography has a high frequency probe, which improves performed.1
the ability to penetrate tissues, can observe the adhesive 5. The wire loop electrode is pushed out totally, and the pos-
tissues and dead cavity formed after adhesions, distin- terior lobe of vaginal speculum is taken for fulcrum at the
guish between the calcification focus and the residual cutting of the anterior lip, and there is no exact fulcrum at
fetal bone, and distinguish the strong echo formed after the cutting of posterior lip.
electroresection of muscular wall from the intrauterine 6. The cutting usually starts from the 6 o’clock position in a
residual ring or fetal bones. So, it is helpful to make a clockwise direction (if cutting starts from anterior lip, the
definite diagnosis and also to guide exactly the operating occurrence of lots of bleeding may affect the cutting of
process. Since laparoscopic ultrasonography is invasive
procedure, it can be applied only when a definite diagno- 1
For reference: Bian Meilu, Liu Shufan. Diagnosis and treatment of
sis is hard to make combined with diagnostic laparoscopy cervical diseases. Beijing: Scientific and Technical Documentation
or transabdominal or transvaginal ultrasonography. Press. 2001,5.
posterior lip). First, step on the foot pedal, and when the Postoperative Precautions
hands feel a sense of cutting action, move the cutting 1. A slight lower abdominal pain may develop 1–3 days
handle or spring, and excise the tissues according to the after operation. A two-week rest and less exercise should
expected cutting depth. When doing with “arc cutting” be prescribed.
from the inside to the outside, the cutting speed should 2. Vaginal discharge for 2–3 weeks after operation is bloody,
not be fast, or the electrocoagulation applied in the and hemorrhagic during decrustation.
blended current cannot play its function well, resulting in 3. After operation, there is exudate from the cutting surface
bleeding. In principle, the wire loop electrode is used and more vaginal discharges, which may last about
under direct vision to coagulate the bleeding points, and 4 weeks.
the wound oozing may be stopped by electrocoagulation 4. Generally, it takes 8 weeks for the cutting surface to heal
with rollerball electrode. If there is severe erosion and completely, so sexual intercourse is banned during this
congestion in the cervix, the rollerball electrode is first period.
used to coagulate the cervix, and then the wire loop elec- 5. When the amount of bleeding is more than that of menses,
trode is used instead so as to reduce bleeding. Sometimes, vaginal examination should be undertaken. If there is active
there are multiple Nabothian cyst underlying the smooth bleeding, iodoform gauze can be placed on the cutting sur-
epithelium, the cutting may be properly extended to face for hemostasis by compression and be removed after
destroy the Nabothian cyst so as to ensure a thorough placement for up to a maximum of 1 week. If it still cannot
treatment. stop bleeding, electrocoagulation should be performed
7. After cutting, the cervix appears to be “shallow urn- under direct vision of hysteroscope, simultaneously antibi-
shaped” or “mushroomhead” in shape. otics should be administered to prevent infection.
ppendix 3: Patient Consent Form
A
for Hysteroscopic Operation
in the Hysteroscopy Center of Fuxing
Hospital, Capital Medical University
Patient Consent Form for Hysteroscopic Operation
Name: Age: Admission number:

1.Preoperative Diagnosis: menorrhagia dysfunctional uterine bleeding uterine fibroid
cervical polypoid hyperplasia others
2.Diagnostic foundations: history of illness physical examination ultrasonography
laboratory tests diagnostic hysteroscopy
3.Proposed surgery: TCR-
4.Indications: menorrhagia anemia or leucorrhea which affects health
5.Anesthesia: venous continuous epidural anesthesia
6.Intraoperative and postoperative complications and managements
1) Bleeding: strict hemostasis, blood matching preparation for spare use.
2) Infections: Strict sterile operation, preoperative and postoperative use of antibiotics.
3) Injuries: Distinguish anatomical structure and operate carefully to avoid side injuries as far as
possible. Once an injury occurs, timely repair or delayed repair will be conducted,or
hysterectomyif necessary.
4) TURP syndrome.
5) If there is much bleeding during surgery, and cannotbe controlled after measures are taken,
conversion to laparotomy is required if necessary.
6) Air embolism: Promptly rescue.
7) The patients who had previous tubal sterilization may develop PASS syndrome following
TCRE. Successive intrauterine exploration may be conducted for 2 months.
8) Anesthetic accidents: Promptly rescue.
7. Postoperative outcomes
1) Amenorrhea.
2) Significantly reduced period.
3) The patients with no significantly improved period or recurrence require further treatment.
4) The patient’s ovarian function is not affected.
5) The patient with myomas that could not be resected or failed to be removed completely needs
continued observation or treatment.
8. Preoperative preparations
Skin preparation, blood matching, preoperative cervical intubation
9. Patient`s consent and signature:
Physician:
Month Day Year

ppendix 4: Patient Consent Form
A
for Hysteroscopic Diagnosis
in the Hysteroscopy Center of Fuxing
Hospital, Capital Medical University
Patient Consent Form forHysteroscopic Diagnosis
Name: Age: Diagnosis:
Diagnostic hysteroscopy is a minimal invasive examination for diagnosing lesions in

uterine cavity and cervical caal. It can directly observe the abnormalities in cervix
and uterine cavity, and take target biopsy of suspected lesions. However, the uterine
cavity is narrow and small with plenty of blood supply of uterine walls. The
pathology causes changes in normal anatomy of the uterus, so there may be some
conditions occurring during diagnostic procedure as follows:
1. Bleeding.
2. Perforation and damage to other organs.
3. Reaction of artificial abortion syndrome.
4. Air embolism.
The following conditions may occur after procedure:
1. Bleeding.
2. Infection.
It is common responsibility of doctors and patients to understanding these information.

Surgeons will strictly obey the operating rules during diagnostic procedures to
maximally avoid the occurrence of above accidents. Since the patient may have her
own features of health conditions, individual difference, and some unpredictable
factors, it is possible to develop some accidents during hysteroscopic diagnosis. The
doctors will deal with it promptly and conduct repair if necessary. The patient and her
relatives are supposed to understand and accept these issues.
The patient signs to confirm that: I haveread the content of this protocol; I
give consent to undergo diagnostic hysteroscopy; I understand and agree with the
hysteroscopic process explained in this protocol, including the risksof diagnostic
hysteroscopy, Therefore, I sign as follows:
Patient`s signature: Doctor`ssignature:
Date: Date:

ppendix 5: Report of Diagnostic
A
Hysteroscopy
International Hysteroscopy Training Center

Hysteroscopy Center of Fuxing Hospital, Capital Medical University
Report of diagnostic hysteroscopy combined with B-ultrasonography
Serial number:
Name: Age: Case No.: Date:13thAugust 2014
Indications:
Menstrual and obstetrical history: MC: LMP: G/P:
Gynecological examination: Vulva:married type; Vagina: unobstructed; Cervix: smooth; Uterus:

anteverted, normal size, movable and without tenderness;
Adnexa: no abnormalities in both sides.
Clinical diagnosis: uterine malformation
Preoperative preparation:Anesthesia: local infiltration anesthesia Dilation of cervix:

length of uterine cavity: cm
Findings under hysteroscope:
Intraoperative intervention: Curettage: g; Endometrialthickness: mm; IUD removal:
Combined diagnosis:
Postoperative treatment:waiting for histological result; out-patient re-check one week later;
Examining physicians: Recording physician:
Precautions after hysteroscopy:

1. Please read these items carefully after hysteroscopy.
2. A small amount of bleeding within one weekfollowing hysteroscopy is normal. Please come
and see your doctor if it reaches the amount of period.
3. Please come and see your doctor or call your doctor if your experiences abdominal pain and
fever.
4. Sexual intercourse and bathare banned within one month.
5. Please come and have further consultation with your doctor one week later and get your
histological report.
6. Contact number: 88062548.


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Enlan Xia

ISBN 978-981-19-1331-0 ISBN 978-981-19-1332-7 (eBook)

© Henan Science and Technology Press 2022

Beijing, China Enlan Xia

December 20, 2008 Enlan Xia

June 2002 Enlan Xia

Beijing, China Jinghe Lang

Appendix 1: Routine Orders in a Hysteroscopic Ward ���������������������������������������� 441

Appendix 2: A Practical Manual of Hysteroscopic Surgery ���������������������������������� 449

Appendix 5: Report of Diagnostic Hysteroscopy�������������������������������������������������� 465

About the Editor

Enlan Xia, graduated from Northwestern Medical College in

other regions for communication and lecturing. She has held 12

Handong Cai Department of Anesthesiology, Fuxing Hospital, Capital Medical University,

© Henan Science and Technology Press 2022 1

viscosity distention fluid. In 1927, Mikulicz-Radecki 1.8 A Clinical Review

© Henan Science and Technology Press 2022 7

Fig. 2.1 SurgMaster

2.1.2.1 Cold Light Source

Fig. 2.5 Light guide bundle

cally or manually. It also has an emergency lamp (150 W

2.1.2.2 Light Guide Bundle

Fig. 2.8 Standard camera head. (a) Vertical. (b) Curved

Fig. 2.9 Adapter. (a) 0.8 magnification. (b) 1.2 magnification

venient for cleaning. The video camera head is waterproof so

2.1.4.4 Other Application Systems

2.2 Instruments for Hysteroscopic

There are two types of hysteroscope according to different

2.2.1 Fiber Hysteroscope

2.2.1.1 Diagnostic Fiber Hysteroscope (Fig. 2.14)

Table 2.1 Comparison between rigid hysteroscope and fiber

vision when fixed with Lin’s outer sheath for continuous-­

1. Flexible therapeutic fiber hysteroscope (Fig. 2.18): It has

2.2.2 Rigid Hysteroscope

Such hysteroscope has a rigid appearance, consists of an

2.2.2.1 Diagnostic Rigid Hysteroscope

2.2.2.2 Therapeutic Rigid Hysteroscope

Fig. 2.23 Integrated hysteroscope

2.3 Instruments for Hysteroscopic

At the beginning of hysteroscopic surgery, the pioneers, such

Fig. 2.24 Hystero-resectoscope

Fig. 2.27 Hysteroscopic sheath

2.3.1.3 Hysteroscopic Sheaths (Fig. 2.27)

Fig. 2.29 Wire loop electrode

Fig. 2.28 ABS (anti blocking system)

2.3.2 Active Electrodes

The resectoscope is often used with a monopolar electrode

2.3.2.1 Wire Loop Electrode

Fig. 2.34 Roller barrel electrode

Fig. 2.33 Roller ball electrode

2.3.2.4 Roller Bar/Roller Barrel Electrode Fig. 2.35 Vaporizing electrode

• Cutting in saline can be done without TURP syndrome,

Fig. 2.38 SurgMaster multifunctional high-frequency electrosurgery

weight: 112 g→83 g, total weight: 248g

add 11.5 mm, total working length: 194 mm

8.5 mm Cutting group has same quality and

• Avoidance of obturator nerve reflex;

2.4 Cleaning, Sterilization,

peroxide (H2O2), active oxygen atoms (O), active hydro-

Beijing, China Enlan Xia

December 20, 2008 Enlan Xia

June 2002 Enlan Xia

Beijing, China Jinghe Lang

Appendix 1: Routine Orders in a Hysteroscopic Ward �� 441

Appendix 2: A Practical Manual of Hysteroscopic Surgery �� 449

Appendix 5: Report of Diagnostic Hysteroscopy�� 465

viscosity distention fluid. In 1927, Mikulicz-Radecki 1.8 A Clinical Review

2.1.2.1 Cold Light Source

2.1.2.2 Light Guide Bundle

2.1.4.4 Other Application Systems

2.2 Instruments for Hysteroscopic

2.2.1 Fiber Hysteroscope

2.2.1.1 Diagnostic Fiber Hysteroscope (Fig. 2.14)

vision when fixed with Lin’s outer sheath for continuous-

2.2.2 Rigid Hysteroscope

2.2.2.1 Diagnostic Rigid Hysteroscope

2.2.2.2 Therapeutic Rigid Hysteroscope

2.3 Instruments for Hysteroscopic

2.3.1.3 Hysteroscopic Sheaths (Fig. 2.27)

2.3.2 Active Electrodes

2.3.2.1 Wire Loop Electrode

2.3.2.4 Roller Bar/Roller Barrel Electrode Fig. 2.35 Vaporizing electrode

2.4 Cleaning, Sterilization,

2.4.2.1 Autoclave Sterilization

2.4.2.2 Low Temperature Sterilization

2.4.5 Storage After Operation

4.1 Preoperative Medication 4.1.1.1 Pseudo-Pregnancy Therapy

4.3 Clomiphene pituitary to secrete gonadotropins, thus starting or inducing

5.1.2 Current Types in Hysteroscopic

5.1.2.1 Cutting Current

5.1.2.3 Blended Current

5.2.2 Influence of the Electrothermal Effect

5.2.2.1 Influence of Current Wave Patterns 5.2.2.3 Setting of Electrode Power

5.3.3 Application of High Frequency 5.3.4 Application of High Frequent Bipolar

6.5.1.1 Calculation of the Serum Sodium Deficit

6.6.2 Prevention of Complications Caused by

8.1.1.5 Secondary Dysmenorrhea 8.1.2.2 Relative Contraindications

8.1.5 Timing of Hysteroscopy

8.1.9 A Normal Uterus Under Hysteroscopy

8.1.9.1 Various Images Seen by Hysteroscopy

8.1.10 Abnormal Findings Under

8.1.10.1 Submucosal Myoma

8.1.10.4 Intrauterine Foreign Bodies