Accuracy of Hysteroscopic Metroplasty With the Combination of Presurgical 3-Dimensional Ultrasonography and a Novel Graduated Intrauterine Palpator: A Randomized Controlled Trial

Abstract

STUDY

Objective: To assess whether the use of a novel graduated intrauterine palpator can improve the accuracy of hysteroscopic metroplasty, introducing objective intraoperative criteria.

Design: A prospective randomized study (Canadian Task Force I, evidence obtained from a properly design, randomized, controlled trial).

Setting: University Federico II hysteroscopic clinic.

Patients: Ninety women with a uterine septum diagnosed during office hysteroscopy and 3-dimesional transvaginal ultrasound (3D-TVS) were randomized into 2 groups: group T (metroplasty with intrauterine palpator) (n = 45) and group C (metroplasty without intrauterine palpator) (n = 45).

Interventions: Outpatient hysteroscopic metroplasty under conscious sedation using a 5-mm hysteroscope and miniaturized 5F instruments including a bipolar electrode for the removal of three quarters of the septum, blunt scissors to refine the base of the septum, and an intrauterine palpator to measure the portion of the removed septum (only group T). 3D-TVS and second-look hysteroscopy were used to identify the number of optimal (residual septum <5 mm), suboptimal (residual septum 5-10 mm), and incomplete resections (residual septum >10 mm). In group T, metroplasty was stopped when the intrauterine palpator showed that the resected septum corresponded to presurgical ultrasonographic measurements in order to obtain a fundal notch of 1.0 cm. In group C, metroplasty was interrupted once the tubal ostia were clearly visible on the same line and/or hemorrhage from small myometrial vessels of the fundus was observed.

Measurements and main results: No differences were observed in baseline characteristics between the 2 groups. The proportion of patients with complete septum resection was significantly higher in group T (71.5% vs 41%, χ(2): p = .006; relative risk: 1.684; 95% confidence interval, 1.116-2.506). Suboptimal resection was achieved in 13 cases (28.5%) in group T and 14 cases (20%) in group C, whereas incomplete resection was observed in only 12 patients in group C (27%).

Conclusion: Presurgical evaluation with 3D-TVS together with the use of a graduate intrauterine palpator improves the accuracy of hysteroscopic metroplasty, allowing complete removal of a uterine septum in 1 surgical step.

Keywords: 3-Dimensional ultrasonography; Hysteroscopy; Residual septum; Uterine septa.