Laparoscopic Metroplasty in Bicornuate and

Didelphic Uteri: Feasibility and Outcome

Saeed Alborzi, M.D. Professor of Obstetrics & Gynecology

Specialist in Infertility & Gynecologic Endoscopy Shiraz University of Medical Sciences,

Shiraz, Iran

Introduction• Müllerian duct anomalies are common causes of recurrent

pregnancy loss and poor pregnancy outcomes. • The prevalence of these malformations in general population is

approximately 5%, while it is 5-10% in those suffering from recurrent miscarriages and above 25% in late pregnancy losses and preterm deliveries .

•  Among the Müllerian duct anomalies, bicornuate and didelphic uteri are common forms, with the prevalence of 25% and 11%, respectively

• The complications associated with Müllerian duct anomalies include recurrent spontaneous pregnancy losses in first trimester, infertility, IUGR, preterm labor, preterm delivery and fetal malposition.

• The pregnancy outcome in pts with these anomalies is not favorable. •  Previous reports have demonstrated that those with bicornuate

uterus have higher rates of abortion and preterm delivery equal to 36% and 23%, respectively.

•  In the same way, the rates of abortion and preterm delivery in pts with didelphic uterus are 37% and 16.4% . The pregnancy outcome in these pts could only be preserved through surgical procedures.

•  In other words, surgical intervention remains the standard of care for those with Müllerian duct anomalies suffering from recurrent pregnancy loss or poor pregnancy outcome .

•  The Strassman metroplasty is the standard surgical procedure for correction of the bicornuate and didelphic uteri.

•  Laparoscopic metroplasty is reported to be feasible and associated with less complications including bleeding, adhesion formation and duration of hospitalization.

• There are a few articles which reported the feasibility of laparoscopic metroplasty in didelphic and bicornuate uteri.

• We have previously reported 4 cases of laparoscopic metroplasty in bicornuate and didelphic uteri with good results regarding uterine cavity and adhesion formation.

•  The present report is thus far the largest case series on laparoscopic metroplasty in bicornuate and didelphic uteri not only to evaluate the feasibility of the operation but also the pregnancy outcome.

Materials and Methods • Study population

• This study was conducted on 26 pts who revealed history of two times abortion or preterm delivery (not explained by hormonal, genetic, immunologic causes) and sonohysterography-confirmed diagnosis of bicornuate or didelphic uteri.

• Our sequential sampling enrolled 4 pts of didelphic and 22 pts of bicornuate uteri who had referred for laparoscopic metroplasty to a university and two private hospitals in Shiraz, Iran, between 2007 and 2013.

• We excluded those pts who were lost to follow up (6 cases), and also six others whose duration of follow up was less than 12 months after the second-look laparoscopy.

•  The study protocol was approved by the institutional review board and the ethics committee of Shiraz University of Medical Sciences.

• All pts and their husbands provided their informed written consents before inclusion in the study.

Surgical procedure • All the pts underwent diagnostic hysteroscopy before the operation.

Laparoscopic metroplasty was performed in all pts by the same surgeon.

• Preoperative antibiotic was given as prophylaxis. A 10-mm trocar was inserted under the umbilicus and CO2 with pressure of 15 mmHg was insufflated to the abdominal cavity. Under direct view, a 5-mm trocar was placed in RLQ and medial to the epigastric vessels. Another 10-mm trocar was inserted under direct vision in LLQ, lateral to the epigastric vessels. A 5-mm trocar was also inserted between the two trocars.

•  An adhesion band between the rectum and the bladder was usually present in didelphic uterus that was resected.

• Vasopressin 20 mL at a concentration of 5 mIU/100 mL saline solution was infiltrated along the medial aspect of both the uterine horns.

Then, an incision was made from 1-cm to the right cornua to 1-cm to the left cornua using hook monopolar (50 watts cutting current). The cavity of the uterus was entered with hook scissor. Anterior to anterior and posterior to posterior wall repair of the uterus was performed, using several interrupted 0 polyglactin 910 ( Vicryl;Ethicon, Somerville, NJ)excluding endometrium

• Afterwards, the serosa and the superficial myometrium were repaired using continuous baseball sutures with 4-0polyglactin 910 (Vicryl;Ethicon,Somerville,NJ)

• After irrigation of the abdominal cavity with saline solution and evaluation of the bleeders, Interceed (ETHICON SARL, Neuchatel, Switzerland) was applied on the site of incision. After evacuation of CO2 from the peritoneal cavity, the sites of cannulas were closed by a monofilament suture.

•  Intravenous antibiotic was administrated for all the pts until the second postoperative day. Pts were discharged and were given 2.5 mg Conjugated estrogen, daily for 21 days and 10 mg medroxy progesterone acetate, daily for the last 10 days of menstrual cycles for 2 months for endometrial proliferation and prevention of intra-uterine synechia .

•  All the pts underwent second-look laparoscopy and hysteroscopy 3 months later for evaluation of uterine cavity, its compliance and possibility of adhesion formation

• Patients were advised to attempt conceiving one month after the second-look laparoscopy (i.e. 4 month after the main operation).

Follow-up and outcome assessment

• All pts were supposed to be followed for at least 12 months for occurrence of pregnancy.

•  We recorded the uterine cavity compliance, adhesion formation, complications, pregnancy rate, and live birth rate

Results • Overall we operated 26 pts, but 12 were excluded from the final

analysis due to loss of follow-up or less than 12 months follow-up after second look operation.

• Thus the final number of pts included in the final analysis was 14.

• The mean age of the pts was 31.6 ± 6.3 (ranging from 22 to 39) yrs.

• These 14 pts had history of 29 conceptions including 25 abortions and 4 preterm deliveries.

• Among the pts there were 10 bicornuate and 4 didelphic uteri.

• All the pts were discharged two days after the operation. •  low grade fever was detected in one pt that was successfully

treated with antibiotics and was discharged on the third postoperative day.

• The second look laparoscopy showed minimal adhesion of omentum to uterus in 8 pts which was released easily.

•  In second look hysteroscopy, all the pts showed uniform and suitable uterine cavity with good compliance which was evaluated by increased intrauterine pressure up to 150 mmHg with a continuous positive pressure infusion of 5% dextrose in water. However, subseptums less than 1 cm in height were seen in 7 pts and were removed by resectoscope.

• No significant complication was occurred during or after operation

• Over 85% of cases (12/14) succeeded to become pregnant within the first year and 14.2% (2/14) postponed conception.

• Nine patients (7 bicornuate and 2 didelphic uteri) had term pregnancy with normal pregnancy and delivery outcomes. There were 2 abortions in bicornuate group and one preterm delivery in didelphic group which had incompetent cervix and had preterm delivery at 22 weeks though vaginal cerclage had been done at 14 weeks of gestation.

•  Two (1 bicornuate and 1 didelphic uteri) pts decided to postpone conception due to personal reasons.

• A pt with bicornuate uterus developed placenta previa and placental site bleeding that was managed conservatively.

• The method of delivery was cesarean section for all cases and they delivered 9 live neonates.

Discussion • The results of this study indicate that laparoscopic

metroplasty is a feasible, safe and effective treatment of Müllerian duct anomalies including bicornuate and didelphic uteri.

•  We operated 26 cases of bicornuate and didelphic uteri successfully with good results regarding uterine cavity compliance and minimal adhesion formation.

• Fourteen cases were included for evaluation of outcome of pregnancy as they had at least 12 months of follow up.

•  Overall 12 pregnancies were occurred which led to 9 term pregnancies and live births

• The number of abortions and preterm deliveries after the operation was low ( 16.6% and 8.3%, respectively) and the outcome of pregnancy seems to be favorable in most pts.

•  Post-surgery abortion was in the first trimester and preterm delivery was found to occur at a more advanced gestational age (22weeks) as compared to previous pregnancy loss (18 weeks). Thus, we suggest laparoscopic metroplasty for correction of bicornuate and didelphic uteri.

• To the best of our knowledge, this is the largest study reporting the pregnancy outcome and feasibility of the laparoscopic metroplasty for treatment of bicornuate and didelphic uteri.

• The first case of laparoscopic metroplasty for bicornuate uterus was reported by Sinha and co-workers in 2006

•  We have reported the first case of laparoscopic metroplasty for didelphic uterus in 2009

•  Then, a few other reports appeared in the literature indicating the safety and effectiveness of laparoscopic metroplasty for Müllerian duct anomalies

• In the previous decade, laparoscopy was mostly a diagnostic tool, but currently most of the major operations and surgical interventions are being performed via laparoscopy by skilled surgeons.

• Laparoscopic procedures are associated with less operative bleeding, less postoperative infection, and shorter hospital stay. Laparoscopy could be safely used for Strassman metroplasty with favorable outcome.

• The most important benefit of laparoscopic metroplasty is reduced rate of intra-abdominal adhesions, which play important role in etiology of secondary infertility especially tubal factors. The lower incidence of adhesion formation after laparoscopy might be due to reduced tissue handling and chance of drying.

• This should be kept in mind that metroplasty should be reserved for those pts with double uteri cavity who have previous history of recurrent pregnancy loss and preterm delivery as the pregnancy outcome will improve in these groups.

•  Those with primary infertility would not benefit from the intervention

•  Heinonen demonstrated that fetal survival improved from 3% to 86% after the abdominal metroplasty in those with recurrent abortion or preterm delivery

• The suturing technique of uterine layers is the most important factor in improving outcome of operation.

• When suturing the myometrium, it should be ensured that the edges are aligned without tensions and hematoma. These precautions are necessary to reduce the likelihood of healing by secondary intention which could make the uterine wall fragile during pregnancy.

• At the end of the second look operation, we evaluated the uterine compliance by increasing the intrauterine pressure up to 150 mmHg with a continuous positive pressure flow of DW5%.

• This pressure is even more that the intrauterine pressure in the active phase of the labor (80-100 mmHg).

• However, we performed cesarean section for all the 9 deliveries in order to prevent unpredicted rupture of the uterine wall.

conclusion•  laparoscopic Strassman metroplasty is a safe, feasible and effective approach in treatment of pts with bicornuate and didelphic uteri suffering from recurrent pregnancy loss or preterm delivery.

•  Of course, more long-term studies should be performed on larger sample sizes in order to confirm the favorable pregnancy outcomes.