Endometrial Poliplerin Yönetiminde Histeroskopi
Özet
Endometrial polipler, endometrial mukozadan kaynaklanan, genellikle anormal vajinal kanama veya infertilite ile ilişkilendirilen benign tümörlerdir. Histopatolojik olarak hiperplastik, fonksiyonel, atrofik, psödopolip ve adenomatöz olarak sınıflandırılırlar. Kesin nedeni bilinmemekle birlikte genetik, hormonal, inflamatuar ve iatrojenik faktörlerin polip oluşumuna yol açtığına inanılmaktadır. Tanıda transvajinal ultrasonografi ve sonohisterografi kullanılsa da altın standart yöntem histeroskopi kılavuzluğunda biyopsidir. Tedavinin temel amacı semptomları gidermek ve malignite riskini ekarte etmektir. Küçük polipler mekanik enstrümanlarla çıkarılabilirken, daha büyük lezyonlar için bipolar elektrotlar, rezektoskopik dilimleme veya komplikasyon riski daha düşük olan histeroskopik morselatörler tercih edilmektedir. Atipik fokal hiperplazi varlığında ilk seçenek histerektomi olsa da fertilite koruyucu konservatif yaklaşımlar da uygulanabilir. Güncel kanıta dayalı kılavuzlar, semptomatik postmenapozal kadınlarda bekle-gör yaklaşımının önerilmediğini, kör tekniklerden kaçınılması gerektiğini ve 2 cm'den büyük asemptomatik poliplerin çıkarılması gerektiğini belirtmektedir.
Endometrial polyps are benign tumors originating from the endometrial mucosa, which are generally associated with abnormal vaginal bleeding or infertility. Histopathologically, they are classified as hyperplastic, functional, atrophic, pseudopolyps, and adenomatous. Although the exact cause is unknown, genetic, hormonal, inflammatory, and iatrogenic factors are believed to lead to polyp formation. While transvaginal ultrasonography and sonohysterography are utilized in diagnosis, the gold standard method is hysteroscopy-guided biopsy. The primary goal of treatment is to relieve symptoms and rule out the risk of malignancy. Small polyps can be removed with mechanical instruments, whereas larger lesions are preferred to be treated with bipolar electrodes, resectoscopic slicing, or hysteroscopic morcellators, which offer a lower risk of complications. Although hysterectomy is the first choice in the presence of atypical focal hyperplasia, fertility-sparing conservative approaches can also be applied. Current evidence-based guidelines indicate that a watch-and-see approach is not recommended for symptomatic postmenopausal women, blind techniques should be avoided, and asymptomatic polyps larger than 2 cm must be removed.
Referanslar
Salim S, Won H, Nesbitt-Hawes E, et al. Diagnosis and management of endometrial polyps: a critical review of the literature. J Minim Invasive Gynecol. 2011;18(5):569-581. doi: 10.1016/j.jmig.2011.05.018
Anastasiadis PG, Koutlaki NG, Skaphida PG, et al. Endometrial polyps: prevalence, detection, and malignant potential in women with abnormal uterine bleeding. Eur J Gynaecol Oncol. 2000;21(2):180-183.
Dal Cin P, Vanni R, Marras S, et al. Four cytogenetic subgroups can be identified in endometrial polyps. Cancer Res. 1995;55(7):1565-1568.
Lo KW, Yuen PM. The role of outpatient diagnostic hysteroscopy in identifying anatomic pathology and histopathology in the endometrial cavity. J Am Assoc Gynecol Laparosc. 2000;7(3):381-385. doi: 10.1016/s1074-3804(05)60482-3
Garuti G, Centinaio G, Luerti M. Outpatient hysteroscopic polypectomy in postmenopausal women: a comparison between mechanical and electrosurgical resection. J Minim Invasive Gynecol. 2008;15(5):595-600. doi: 10.1016/j.jmig.2008.07.001
Stamatellos I, Apostolides A, Stamatopoulos P, et al. Pregnancy rates after hysteroscopic polypectomy depending on the size or number of the polyps. Arch Gynecol Obstet. 2008;277(5):395-399. doi: 10.1007/s00404-007-0460-z
Cholkeri-Singh A, Sasaki KJ. Hysteroscopy for infertile women: a review. J Minim Invasive Gynecol. 2015;22(3):353-362. doi: 10.1016/j.jmig.2014.12.163
Wang JH, Zhao J, Lin J. Opportunities and risk factors for premalignant and malignant transformation of endometrial polyps: management strategies. J Minim Invasive Gynecol. 2010;17(1):53-58. doi: 10.1016/j.jmig.2009.10.012
Cohen I. Endometrial pathologies associated with postmenopausal tamoxifen treatment. Gynecol Oncol. 2004;94(2):256-266. doi: 10.1016/j.ygyno.2004.03.048
Alcázar JL, Galan MJ, Mínguez JA, et al. Transvaginal color Doppler sonography versus sonohysterography in the diagnosis of endometrial polyps. J Ultrasound Med. 2004;23(6):743-748. doi: 10.7863/jum.2004.23.6.743
Tahmasebi F, Stewart S, Mitra A, et al. Transvaginal Saline Contrast Sonohystography to Investigate Postmenopausal Bleeding: A Systematic Review. Cureus. 2020 Aug 28;12(8): e10094. doi: 10.7759/cureus.10094
Bafna UD, Shashikala P, Nagarathna DS. Correlation of endometrial ultrasonography and endometrial histopathology in patients with postmenopausal bleeding. J Indian Med Assoc. 2006;104(11):627-629.
Laifer-Narin S, Ragavendra N, Parmenter EK, et al. False-normal appearance of the endometrium on conventional transvaginal sonography: comparison with saline hysterosonography. AJR Am J Roentgenol. 2002;178(1):129-133. doi: 10.2214/ajr.178.1.1780129.
Syrop CH, Sahakian V. Transvaginal sonographic detection of endometrial polyps with fluid contrast augmentation. Obstet Gynecol. 1992;79(6):1041-1043.
Makris N, Skartados N, Kalmantis K, et al. Evaluation of abnormal uterine bleeding by transvaginal 3-D hysterosonography and diagnostic hysteroscopy. Eur J Gynaecol Oncol. 2007;28(1):39-42.
Bettocchi S, Nappi L, Ceci O, et al. What does 'diagnostic hysteroscopy' mean today? The role of the new techniques. Curr Opin Obstet Gynecol. 2003;15(4):303-308. doi: 10.1097/01.gco.0000084241. 09900.c8
Sharma M, Taylor A, di Spiezio Sardo A, et al. Outpatient hysteroscopy: traditional versus the 'no-touch' technique. BJOG. 2005;112(7):963-967. doi: 10.1111/j.1471-0528.2005. 00425.x
Kayatas S, Meseci E, Tosun OA, et al. Experience of hysteroscopy indications and complications in 5,474 cases. Clin Exp Obstet Gynecol. 2014;41(4):451-454.
Richlin SS, Ramachandran S, Shanti A, et al. Glycodelin levels in uterine flushings and in plasma of patients with leiomyomas and polyps: implications for implantation. Hum Reprod. 2002;17(10):2742-7. doi: 10.1093/humrep/17.10.2742
Di Spiezio Sardo A, Bettocchi S, Spinelli M, et al. Review of new office-based hysteroscopic procedures 2003-2009. J Minim Invasive Gynecol. 2010;17(4):436-448. doi: 10.1016/j.jmig.2010.03.014
van Dongen H, Emanuel MH, Wolterbeek R, et al. Hysteroscopic morcellator for removal of intrauterine polyps and myomas: a randomized controlled pilot study among residents in training. J Minim Invasive Gynecol. 2008;15(4):466-471. doi: 10.1016/j.jmig.2008.02.002
Garuti G, Luerti M. Hysteroscopic bipolar surgery: a valuable progress or a technique under investigation? Curr Opin Obstet Gynecol. 2009;21(4):329-334. doi: 10.1097/GCO.0b013e32832e07ac
Garuti G, Mirra M, Luerti M. Hysteroscopic view in atypical endometrial hyperplasias: A correlation with pathologic findings on hysterectomy specimens. J Minim Invasive Gynecol. 2006;13(4):325-330. doi: 10.1016/j.jmig.2006.03.010
Di Spiezio Sardo A, Calagna G, Guida M, et al. Hysteroscopy and treatment of uterine polyps. Best Pract Res Clin Obstet Gynaecol. 2015;29(7):908-919. doi: 10.1016/j.bpobgyn.2015.06.005
Vitale SG, Haimovich S, Laganà AS, et al. Endometrial polyps. An evidence-based diagnosis and management guide. Eur J Obstet Gynecol Reprod Biol. 2021; 260:70-77. doi: 10.1016/j.ejogrb.2021.03.017
