Hysteroscopic Management of Uterine Arteriovenous Malformation

Abstract

Background and objectives: Uterine arteriovenous malformation (AVM) is characterized by shunts between the myometrial arteries and veins. Treatment is based on the severity of uterine bleeding and ranges from conservative medical approaches to embolization of affected arteries. The aim of study was to evaluate the feasibility and safety of hysteroscopy for management of uterine AVM.

Methods: This was a retrospective study of a cohort of 11 cases occurring between March 2012 and December 2015 in our Regional Center of Excellence in Hysteroscopy, University of Florence. The diagnosis of AVM was made by transvaginal ultrasonography with high-definition flow in patients with mild to moderate symptoms. In all cases, we used the hysteroscopic platform Gynecare VersaPoint II (Ethicon, Somerville, New Jersey, USA), equipped with a 4-mm electrosurgical loop and associated with the SPIES (Storz Professional Image Enhancement System) system (Karl Storz, Tuttlingen, Germany).

Results: All patients were successfully treated with operative hysteroscopy with no reported complications. No patient had residual disease detected by ultrasonography performed after a month. At this writing, of the 11 patients treated with operative hysteroscopy, 4 had achieved a pregnancy that carried to term, 1 was pregnant at 20 wk, and 1 had a miscarriage in the first trimester.

Conclusions: Hysteroscopy is a feasible and safe alternative treatment modality for AVM. Patients treated with surgical hysteroscopy have high fertility outcomes, a 100% success rate after the first treatment, no complications related to the surgical procedure, and a short hospital stay.

Keywords: Fertility; Hysteroscopic technique; Hysteroscopy; Uterine arteriovenous malformation.

Figure 1.

Visualization with transvaginal ultrasound with color Doppler AVM.

Figure 2.

A, B, Visualization of AVM in the uterine cavity. C, D, Hysteroscopic resection of the lesion.

Figure 3.

A, B, D, Visualization during hysteroscopic resection of large size vessels, with massive bleeding. C, Visualization of the blood vessel during high–flow hysteroscopy.

Figure 4.

A, B, During hysteroscopic resection, partial reduction of bleeding. C, D, Phases vessels coagulation myometrial at increased bleeding.

Figure 5.

A–D, Ultimate vision of the uterine cavity after complete resection of the AVM. A, View of the uterine cavity near isthmus. B, C, Appreciate the void in myometrial wall in the area that was previously occupied by AVM. D, Restoring the integrity of the uterine cavity.