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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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GENERAL PRINCIPLES
Definition
Uterine polyps are localized overgrowths of endometrium. They are common, with a prevalence range from 8% to 35%.
Abnormal uterine bleeding is the most common presentation, occurring in 68% of cases. Spontaneous regression can occur
in 27% of patients after 1 year and is more likely to occur with smaller polyps <1 cm.
1
The majority of polyps are benign,
but premalignancy or malignancy occurs in 5.4% of those in postmenopausal women compared with 1.7% in
premenopausal women.
2
Endometrial polyps are commonly found in infertile women. Overall evidence supports that they have a detrimental effect
on fertility, with improvements seen after surgical removal.
3
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Differential Diagnosis
Submucous myomas, retained placental tissue, intrauterine adhesions
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Nonoperative Management
Observation: Polyps are thought to regress spontaneously in 27% of cases.
1
Medical management: There is no evidence to support medical therapy to treat polyps, though levonorgestrel-IUDs and oral
contraceptive pills can reduce the incidence of polyp formation.
3
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IMAGING AND OTHER DIAGNOSTICS
Polyps can be visualized by several means, including standard 2D transvaginal sonography, 3D sonography, saline infusion
sonography (SIS) (by both 2D and 3D ultrasound), hysterosalpingography (HSG), or hysteroscopy. The use of SIS has
increased diagnostic accuracy over noncontrasted 2D and 3D ultrasound. For SIS studies, the use of 3D imaging may also
provide additional diagnostic accuracy improvements and is comparable to hysteroscopy in diagnosing intrauterine lesions.
3
Polyps can also be diagnosed by HSG, but with a low specificity.
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PREOPERATIVE PLANNING
Preoperative imaging should be used to distinguish polyps from other pathology such as myomas.
Adequate surgical visualization can be achieved by performing the hysteroscopy during the early follicular phase of the
menstrual cycle or by suppressing endometrial growth using hormonal therapy. Suitable hormonal preparation includes oral
contraceptive pills or norethindrone acetate 2.5 to 5 mg daily for 7 to 21 days preprocedure.
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SURGICAL MANAGEMENT
Polypectomy may be performed though several hysteroscopic techniques. Methods of removal include direct removal using
hysteroscopic grasping forceps, resectoscopy, electric power morcellators (MyoSure
®
[Hologic Inc., Marlborough, MA],
Truclear
®
[Smith & Nephew, Andover, MA]), blind polyp forceps, or uterine curettage. Each method has advantages and
disadvantages, and surgeons often need flexibility in using different techniques to properly complete the procedure.
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Positioning
The patient is placed in standard dorsal lithotomy position.
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Approach
Standard hysteroscopic approach is utilized. Procedures can be performed under general anesthesia, moderate sedation, or
under local paracervical block.
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Procedures and Techniques
Performance of diagnostic hysteroscopy
Diagnostic hysteroscopy is performed in the standard fashion to delineate the size and location of cavity lesions (Te ch Fig.
3.4.1). Care should be taken to not dilate the cervix any more than is necessary to allow passage of the scope, to limit fluid
leakage around the scope.
Using a camera with a 12-degree viewing angle allows the best visualization while using rigid grasping forceps or scissors.
Te ch Fig ure 3.4.1. Initial hysteroscopic view of polyp.
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Use of hysteroscopic grasping forceps
A grasping forceps is used to grasp the base of the polyp at the uterine wall attachment. The forceps is moved away from
the polyp base by moving the camera/grasper unit together resulting in tearing the polyp from its attachment (Video 3.4.1
).
Rotating the forceps by ½ turn or more can also be used to tear the polyp from its connection (Tech Figs . 3.4.2, 3.4.3 and
3.4.4).
If the polyp is unable to be torn from its base, a hysteroscopic scissors can be used to cut the polyp from the uterine
attachment.
Te ch Fig ure 3.4.2. Grasping base of polyp.
Te ch Fig ure 3.4.3. Twisting the base of the polyp to shear away from uterine wall.
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