Endometriosis
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Retained Products of Conception: Combined Hysteroscopic Approach with Mechanical Tissue Removal System and Scissors

Retained Products of Conception: Combined Hysteroscopic Approach with Mechanical Tissue Removal System and Scissors
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Video Description

This video demonstrates a combined hysteroscopic approach using a mechanical tissue removal system and scissors for concurrent management of retained products of conception and underlying uterine pathologies. It features two patient cases to demonstrate the approach, one is a case of retained products of conception with intra-uterine adhesions and the other a case of retained products of conception with a uterine septum. The objectives of this video are to enable viewers to (1) recognize the possible concurrent pathologies in cases of chronic or recurrent retained products of conception, (2) understand the benefits of using a combined approach with a mechanical tissue removal system and scissors in the management of these cases, and (3) appreciate how to do so using the same operative hysteroscope.

Presented By

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Dr. Mary Thompson 
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Dr. Lauren Andrew
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Dr. Ari Sanders
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Affiliations

University of Calgary

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What is Retained Products of Conception: Combined Hysteroscopic Approach with Mechanical Tissue Removal System and Scissors?

A combined hysteroscopic approach with a mechanical tissue removal system and scissors is a minimally invasive technique used to remove retained products of conception (RPOC) following miscarriage, delivery, or incomplete abortion. Here’s a breakdown of this approach:

  • Purpose: Retained products of conception refer to residual placental or fetal tissue that remains in the uterus after pregnancy, which can lead to complications like bleeding, infection, or pain. This approach aims to safely and effectively clear the uterine cavity of such tissue.

  • Hysteroscopic Visualization: Using a hysteroscope (a thin, camera-equipped instrument), the surgeon can directly visualize the uterine cavity. This allows for precise removal of retained tissue, minimizing damage to surrounding healthy tissue.

  • Mechanical Tissue Removal System: The mechanical removal system uses specialized instruments designed to remove retained tissue gently and efficiently. This system helps reduce the risk of incomplete removal and minimizes the need for scraping, which can damage the uterine lining.

  • Scissors for Fine Control: Scissors may be used alongside the mechanical system to cut and remove any fibrous or difficult-to-reach tissue, ensuring a thorough clearing of the uterine cavity.

This combined approach is valuable for managing RPOC in a controlled, minimally invasive way, often resulting in a quicker recovery and lower risk of complications compared to more invasive methods.

What are the Risks of Retained Products of Conception: Combined Hysteroscopic Approach with Mechanical Tissue Removal System and Scissors?

Using a combined hysteroscopic approach with a mechanical tissue removal system and scissors to manage retained products of conception (RPOC) has several associated risks:

  • Infection: Inserting instruments into the uterus can introduce bacteria, increasing the risk of infection, which can lead to endometritis or other pelvic inflammatory diseases.

  • Uterine Perforation: The use of mechanical removal devices and scissors increases the risk of perforating the uterine wall, which can lead to internal bleeding or damage to surrounding organs.

  • Bleeding: Removing retained tissue may lead to significant bleeding, especially if the uterine lining is damaged or if residual tissue is firmly attached.

  • Adhesion Formation (Asherman Syndrome): Manipulating the uterine cavity can lead to scar tissue formation (intrauterine adhesions), which may result in Asherman Syndrome, causing menstrual irregularities or infertility.

  • Incomplete Removal: There is a risk that some retained tissue may be left behind, requiring additional procedures and increasing the risk of prolonged symptoms or infection.

This approach requires skilled handling to reduce these risks, making thorough patient counseling and careful surgical planning essential.

Video Transcript: Retained Products of Conception: Combined Hysteroscopic Approach with Mechanical Tissue Removal System and Scissors

In this video, we will explore a combined hysteroscopic approach using a mechanical tissue removal system and scissors for concurrent management of retained products of conception and underlying uterine pathologies. After this video, viewers will be able to recognise the possible concurrent pathologies in cases of chronic or recurrent retained products of conception.

To understand the benefits of using a combined approach with a mechanical tissue removal system and scissors in the management of these cases. And understand how to do so using the same operative hysteroscope. The incidence of retained products of conception varies between 1 to 6%. There are a variety of risk factors which may predispose an individual to retained products of conception.

But two important ones in cases of recurrent or chronic retained products of conception are previous uterine surgery and subsequent intrauterine adhesion formation or uterine anomalies such as a uterine septum. While suction D&C has traditionally been the favourite surgical approach for retained products of conception, it is associated with a higher rate of incomplete evacuation, intrauterine adhesion formation and uterine perforation.

Additionally, operative hysteroscopy provides the added benefit of directly visualising the uterine cavity and identifying possible underlying uterine pathologies, a finding that occurs in up to 10% of cases. That 10% is what we’ll be focussing on in this video. While many different approaches exist to hysteroscopic management of uterine pathologies, hysteroscopic scissors are our preferred approach as they avoid the thermal tissue injury that can occur with electrosurgery.

Uterine pathologies, including intrauterine adhesions and septa, are particularly amenable to scissor dissection. We will use the next two cases to demonstrate how to concurrently use a mechanical tissue removal system for management of retained products of conception, followed by hysteroscopic scissors for management of concomitant uterine pathologies. First, a case of retained products of conception and intrauterine adhesions.

Case one features a 33-year-old female, G3P1, who is otherwise healthy with a known history of Asherman’s syndrome. She conceived while awaiting hysteroscopic lysis of adhesions. Her vaginal delivery was then complicated by endometritis and retained products of conception. After failing medical management, she was referred for hysteroscopic resection and lysis of adhesions. Her pre-operative imaging demonstrated a 2 by 2 cm area at the fundus of her uterus, suspicious for retained products of conception.

Step one, complete initial look hysteroscopy wherein you assess the cavity. As you can see here, there is tissue consistent with retained products of conception located at the fundus of the uterus. There are also visible adhesions present throughout the cavity. Step two, the mechanical tissue removal system is introduced into the cavity and used to remove the tissue, working systematically around the specimen and using the base as reference.

Once the majority of the tissue is removed, gentle and targeted resection using the mechanical tissue removal system can be undertaken to achieve a complete resection. At this time, the device can then be removed. Step three, importantly, if the tissue trap is full and additional tissue resection is required, the tissue trap can be emptied and then reattached to facilitate further resection.

Step four, the obturator sheath can then be slid over the hysteroscopic scissors and both inserted through the hysteroscopic port, allowing for usage at the same scope for both aspects of the procedure. Step five, the scissors can then be used for adhesiolysis within the cavity, taking care not to disrupt the underlying myometrium. On final survey, you can see where the retained products of conception and adhesions were previously noted and appreciate the now restored cavity.

The procedure was uncomplicated and the post-procedure hysterosonogram showed a normal uterine cavity. The patient went on to successfully conceive following the procedure and had an uncomplicated vaginal delivery. The second case focusses on retained products of conception with an underlying uterine septum. Case two features a 33-year-old female, G4P0, who is otherwise healthy, with an obstetrical history significant for recurrent pregnancy loss and retained products of conception.

Following another early, spontaneous abortion, complicated by chronic retained products of conception, she was referred for hysteroscopic management. It is especially important to consider possible uterine pathologies, such as a uterine septum, in cases like these which are recurrent or fail traditional surgical management. Pre-operative imaging indicated a 3 by 3 cm heterogeneous lesion in the left cornua, suspicious for chronic retained products of conception.

Again, step one, complete initial look hysteroscopy. Here, you can see tissue located in the left cornua, consistent with chronic retained products of conception. As you sweep over to the right cornua, you can appreciate a partial septum dividing the two sides. Step two, here, you can see the mechanical tissue removal system again being introduced into the cavity and used to remove the tissue in a similar fashion to before.

After all the tissue is successfully removed, you can clearly see an unobstructed view of the left tubal ostia. Step three to four, after the tissue collection trap has been emptied, the obturator sheath can then be slid over the hysteroscopic scissors and together, introduced into the cavity through the same hysteroscope. Step five, again, you can clearly see the septum extending into the cavity. Taking care to use the tubal ostia for reference, the septum is taken down using sharp dissection with the scissors to normalise the cavity.

On final survey, you can see where the retained products of conception and septum were previously noted and appreciate the now restored cavity. The procedure was uncomplicated and the post-procedure hysterosonogram showed a normal uterine cavity. The patient went on to successfully conceive following the procedure and is currently pregnant in her second trimester.

In summary, we hope the takeaway messages from this video are that, one, you should always consider the why in cases of chronic or recurrent retained products of conception, with the answer potentially being concomitant uterine pathologies. Two, a see-and-treat approach can be applied to hysteroscopic management of retained products of conception and incidental findings of uterine pathologies. This approach is not only patient-centred, as it saves the patient from a potential repeat procedure, but also optimises surgical services.

Three, both procedures can be completed using the same hysteroscopic set-up, thereby also saving on operative time and cost. Thank you.