Perspective on the Treatment of Retained Products of Conception (RPOC)
Jose Carugno, M.D. - Associate Professor of OB/GYN, Minimally Invasive Gynecology/Robotic Division Director Department of OB/GYN and Reproductive Sciences, University of Miami. Miller School of Medicine, USA
Shahrzad Ansari, M.D. – Obstetrician and Gynecologist Day General Hospital Surgery Unit, Tehran, Iran Good morning. Good afternoon. Welcome to Carl's stores webinar on reproductive and retained products of conception. Um My name is Artie chill Carey sing. I'm gonna be your moderator for today's webinar. I am the medical director from for Carl's Stores. Uh and by trade I'm a minimally invasive G. Y. N surgeon. I'd like to introduce our two speakers today. Dr Ansari is a reproductive specialist working in day general hospital at the Mayor IVF Institute center in Tehran Iran. Her main interest is infertility and advanced histories, coptic surgery. She has a large volume of experience with the use of history's coptic shavers. Dr Ansari has been invited to give multiple lectures due to her expertise, conduct historiography workshops and has published extensively in the field of gynecology. Our next speaker is dr Jose Tony kurono. He's a board certified in O. B. G. Y. N. With fellowship training advanced minimally invasive gynecologic surgery. He currently is an associate professor of the residency program and functions as the director of minimally invasive G. Y. N. Surgical division at the University of Miami and Miami florida. Dr chrono serves as a board editor for the historiography newsletter of the global community of hysteria Skopje. The journal minimally invasive gynecology are known as J. Mig and board editor for the Journal of the Society of laparoscopic and robotic surgeons. He too has published extensively in the field of hysteria Skopje. So I want to welcome and thank both speakers today. Just a couple of housekeeping items. One um please feel free to ask our speakers any questions that you have. You have a chat feature Q. And a section where you can ask your question and I'll be sure to read that and we'll ask the presenters to provide their answers. Um I also want to make sure that we understand that some of this content today. Um we do have to understand that of the disclaimer and I don't know if I can see the dis cliff. I can if we can play that disclaimer, please sit. Mhm. And we can't I can't read the whole thing. If we can take me off video and just the one disclaimer please. The large one first. Thank you. The content in this presentation is provided for general educational purposes only this presentation does not constitute a representation that any products, techniques or procedures described would necessarily be appropriate or recommended for any particular patient. The decision to utilize or implement any of the medical opinions, techniques and our procedures presented in this program is up to the sole discretion and clinical judgment of each healthcare professional. A healthcare professional must always refer to product labels and instructions for use, including the instructions for cleaning and sterilization if applicable before using any product. I'd also like to mention that the Bugatti shaver and scope will be introduced throughout the presentations. But please note that both the Bugatti shaver and scope is not FDA cleared and is not available and they're both not available for sale in the US. With those housekeeping items out of the way. I would like to introduce dr Tony kurono to go ahead and start bringing his presentation on retained products of conception. Hi thank you for being here. My name is Jose Tony kurono and I'm associate professor for B. G. Y. N. At the University of Miami and the minimally invasive gynecology division director. I would like to thank car stores for inviting me to be here with you to talk about one of the topics that is really a passion of mine which is retained products of conception. I am going to focus more on understanding the clinical condition that the clinical challenge that we temper our conception posed to the clinician and my colleague dr Ansari will then focus on the technical aspect of how to treat this complex condition. I have no financial conflicts to disclose. So let's start with definitions right? Let's start with need to make sure that we differentiate the two different types of retained conceptions. There are there is the re temporal conception, the gynecologic version of the disease. But the way I say it is the patient who delivers right and then she after the end of the pregnancy this could be an abortion and preterm labor full term delivery. She continues to have mild bleeding and spotted and then she can give you a phone call that says listen since I deliver 67 weeks ago. I'm still having this irregular customs. Spotting that is the patient that we're gonna talk about today. Not the patient we has just delivered and has a piece of placenta left inside the uterus and now she has you're in agony and postpartum hemorrhage. That patient needs uterine tonic, that's an obstetrical condition. And the obstetricians know how to deal with it. We are going to talk today about the gynecologic version of retained products of conception To understand a little bit about the disease and we know that the prevalence is up to 6% which is quite common. We we have all seen these conditions are clinical practice and interesting enough it's more common when the pregnancy ends on the second trimester even spontaneously or induced. That's where we have a higher risk of having retained product. What is the theology? Well if the pregnancy have some sort of intervention and there was an excision of retaining products the most common causes that there's inadequate removal and there is some fragment of trophoblastic tissue left behind and that's why they're still there. But there are also some theories that says that there's some micro areas of small abnormal presentation which is the placenta attached too much with a cree to so a small fragment of agreed to. And that's why the placenta doesn't come out entirely of the product conceptions state inside the years after the delivery because there is some sort of of placenta agree to that. Um As far as risk factors in the world. The most common risk factors is those patients who have history of recovering and multiple D. N. C. S. But it's also a theory saying that if the placenta attaches in the lower uterine segment, those patients also have a higher risk of having retained products of conception. As far as symptoms I already told you. So the symptoms at least they're in this slide. But in short is that patient who and to pregnancy whether spontaneously or a termination of pregnancy, preterm first trimester full term pregnancy it doesn't really matter. But after the end of the pregnancy she continues to have Bleeding and bleeding and spotting and irregular bleeding. And one day she bleeds a little bit more and then it's followed smelling this chart and then 678 weeks later she's still having bleeding, hasn't stopped bleeding since the end of the pregnancy. And that is basically the symptoms of uh the what I call the gynecologic version of retained products of conception. The treatment historically has always been blind delusion and such an cora dash. But we all know now that there is a risky procedure. There is risk of heavy bleeding during the procedure. There is risk of uterine rupture. You know the patient universe is just post parent is when it's soft and it's increased risk of urine perforation. There is a chance of infection because there is manipulation of the uterus a very bad complication that you can have because it looks better with the patient also is removing the product and leaving products behind remember the blind directions would attach. It's a blind procedure you cannot see the what you're doing. It's blind. Even if you do it under ultrasound guidance there is still risk of leaving little pieces behind and creating this condition. And then there is also a long term complications like there are fear and very difficult to treat where I interviewed her and additional information that can lead to Ascherman syndrome as for their infertility. But now when I say now has over the last 20 years we have the capacity to look inside the Uterus and perform this procedure. This procedure under direct visualization. So there's no reason to continue to do a procedure blindly. If we now have the capacity to do it under direct visualization and to understand how we got here right how we move away from blind D. N. C. S. And started doing the removal of retained problem under direct visualization. There was the first study published by Dr Szabo In 1984 Where he used the history scope and visualized where the products of conception were in '95 patients. Then he removed the history a scope and did the curettage where it's a guy that criticized because he already knew where the products We're located inside the Uterus. But remember this is 1980 for this is the beginning of his horoscope. There is no distension media they're doing his microscopy with c. 0. 2 The resolution of the histories copy camera was really and if infancy was really bad. So he was a really visionary To start doing this um back in 1984. Over 10 years later Goldberg published very also um Smart study he proceeded has experienced a case series of 16 patient where he said well we're using the history of scope right to look where these probable conceptions are. I'm going to use the receptors go and used the loop of the recent telescope to remove the product and then using with without energy cold. So that's what he did. And he presented his um Kay series with excellent results. Then 10 years later, Cohen re compared this technique of using the receptor scope called to scoop out the retained products of conception under direct visualization compared vs blind DNC finding also excellent results with the removal under direct visualization and those are the stories that landmark studies that brought us to where we are today. Then Golan In 2011 he presented his experience on 159 patients using the 26 French receptor scope which is the most common receptor scope at the time using the same they curate cold. And he concluded that the precision and I'm gonna read this and his conclusion says the procedure seems to preserve the integrity of the uterine cavity averting additional trauma and preserving reproductive capacity of the patient. This is the conclusion that says well basically this is much better than blind DNC. We should not do blind DNC anymore. And this is what's published in 2011. More than 10 years ago now Then in 2000 five something very interesting happened which is the introduction of the respective scope and leader by leader. The resect a scope of the teacher uh sorry the in the introduction of the teacher removal system and then this teacher removal system came to replace the receptors called because they made the procedure way easier to perform. Well. The bottom line is this and I recently published this uh article with my good friend Sergio and luis Alonso were on a visual way we demonstrated why we should not do blind the NCS anymore. And this is what hey you didn't cavity. We retained products of conception might look like there is inflammation see on the left those micro polyps that's the endometrium endometrium lining. Inflame with chronic endometrial tissue uh as a result of having product of conception inside the users for a long time you see those black white structure with the black arrows. Those are the retained products there. So can you imagine in this inflame Indonesian if you do a sharp curettage. That is what I call the devil's three plus this is what happened postpartum. You have an inflamed cavity. If you do D. N. C. That creates trauma and then you're doing both Faces of the Cavity, one over the other and they stick together then there is inflammation of the dimensions as we said and don't forget police parent. There is a hyper stra genic state. This is what I call the devil's triplet trauma with the DNC inflammation of the Indonesian and the hyper stra genic post parent state is the perfect storm for intergenerational and additional information. And this is the parallel number one that I'm gonna give you today and I'm gonna give you seven powers to take home. And the first one is immediately after pregnancy is the most vulnerable time for introduction. In addition information. Don't forget about this devil's triplet, trauma inflammation and hipaa estrogenic state of the postpartum period. Then to simplify things. And I'm gonna try to give this talk and make it as clinical as simple as possible. So you have a patient with retained products of conception. I will you suspect that This is the patient as I told you, she calls you 678 weeks after the resolution of pregnancy and she's still having spotting bleeding. Regular medium for all smelling this job. You do an ultrasound right? But most important you need to look at the symptoms is this patient having symptoms every bleeding with clots. Well that patient will need a cure attached. That is not the patient we're talking about today. We're talking about the patient who has mild symptoms or probably no symptoms. You do an ultrasound. You see there are still retained products of conception, There's something inside the cavity. You can either if the symptoms are very mild or no symptoms can be expected medical management. The there is the resolution of the symptom. If there is resolution resolution of the symptom done, that's it. That patient doesn't need anything if the patient continues to have symptoms. And when I say symptom is this part in this foul smelling discharge, probably this part union, then you need a history Skopje removal of products of conception. And what's really important on the ultrasound is this you need to look at the vascular charity of the retained products. And there is a classification that goes from type zero to type three. Type zero is when the products are sections are basically free just on on top of the endometrium. And then type one that is going to start a little bit of vascular charity in the endometrium. Type two is vascular charity in the endometrium a little bit of the bio media. And then type three there is increased vascular charity in the Endometrium and the Miami medium. And uh the Teresa Alonso published this very graphic paper where there is a correlation of the ultrasound uh images with the history topic images to the Gutenberg classification. And as I said, you know, type zero is here is an a vascular mass. All the products are inside the cavity inside the Indonesian and then there is increased vascular charity minimal, then is increasing vascular and Type three which is the most vascular of them all. There is vascular charity, not only of the endometrium but also in the Miami trip. And this is important because you don't want to be doing a remove all the product of conception of a type three very vascular in an office setting because there is a chance that they will be bleeding. So my per number two is be aware of the vascular charity of the retained products. Because that will determine if this is the case that you should safely you can safely do in an office setting versus you probably want to take that patient to the operating room. But it's not that easy. It's not that easy that you say, well the patient comes, she's just deliver and still bleeding. She has retained products. Now this very interesting paper that looked at the clinical and also some findings of patients were retained products of conception that were taken to the operating room and Some of them actually have retained product but some of them did not. So they they look at 204 patients and they found um That the West Trophoblastic teacher and the vast majority of them are 87%. But they also found 26 patients where the pathology showed no retained products of the section and they try to identify how can we pre op based on ultrasound and clinical symptoms determine who actually has products of conception in size and who doesn't have. She has just claws. And there is no product. And interesting enough, there is no way to differentiate those two symptoms the same amount of vaginal ability, the same kind of infection at the same time of diagnosis and the ultrasound findings were exactly the same. Whether the patient had retain product. Trophoblastic teacher inside the uterus or not, which is really interesting. And this gives me to the 30 millimeter myth. There is a myth that if the patient End the pregnancy and she has in the mutual lining thicker than 30 then she needs intervention. That is not necessarily true. And it's reinforced on the Eco practice bulletin. What it says, the thickness. It's not a criteria to for intervention. You must look at the symptoms And this gives me the power number three. It is impossible to free up to ensure that the patient has actually retained products of conception inside the uterine cavity and the thickness of the Indonesia aligning. It's really irrelevant. What's important is the symptoms that the patient has. Well, the fear that one of the most common complications and one that we fear the most. It's infertility, right? But it is the procedure is this the dilation credentials and the history of Skopje removal that we do because the patient has retained Brothers African section that causes the infertility or is the tissue itself that causes. And this story. Look at, Try to answer that question. And they look at 240 patients in which they have suspected retained products. They actually found in the pathology, 67% of the patients tissue diagnosis, they there was trophoblastic tissue. But in 22% there was not, there was just clots. And when the products were present, when there was actually trophoblastic tissue inside the unit, the patient had more infertility. They have longer time to conception after for subsequent pregnancy. And they have a higher incidence of I mean, real statistically significant. So the press is of president of conception, retained from a long time. They do cause infertility and they do affect the fertility outcomes for awards. Um what are the you into your own additions creation after the history Skopje treatment of retained product. Uh And they try to to in the to look So we fear what we fear the most is interesting and additions. Right? So they were determined that we have to do this under direct visualization historias copies. But what are the risk factors that whether we do this procedure. History of conflict was still going to have Re introduction of the information that they look at. 167 patients Of them, 84 had actually a follow up history Skopje. And they determined that the risk factors the most important risk factor for intercultural and this information is when the pregnancy end up in the C section. Um they look they almost 50% actually had into Iran this information, Vaginal delivery? 14% and after the abortion 17%. But they look at all the other risk factors as age, gravity. The parity, the interpret between the index pregnancy that resulted in retained president conception and the procedure. And there was no effect at all. Which gives me the power number four. When the retain product conception occur after a C. Section, the risk of internationalization information is the highest. So beware when you have a pigeon we retain product that the index pregnancy and that in Assisi. But why do we fear so much these intra uterine additions? What other productive outcome of patients who actually have additional information? And this study looked at that and Look at the consequences? Look, 152 patients which is who had intra urination information versus those who had no interest in information after the retained part of our conception, the subsequent of surgical outcome a reproductive outcome actually say The pregnancy rate was way lower, 58% versus 90% of those who had no internationalization. The life birth. What was less the time of conception was almost double higher chance of having pretend delivery and a higher chance of having complications. So intramural and additional information definitely has at deleterious are about reproductive a bad impact under for the reproductive outcomes of the patient. What is the risk of recurrence? And this is the question that I get asked very often doctor I have this retained product conception. If I get pregnant again, what are the chances of this happening again? And This study answered that question. They look at 442 patients who were treated for retaining products. Some of them 87% were treated um history aske optically but some how did a blind DNC. Because unfortunately we still see that very often still performing clinical practice and they found that the chances of having Recurrence of retaining the and the subsequent pregnancy is about 15%. If the index pregnancy was an aversion, About 27% of the index pregnancy was a labor of full term pregnancy. But what's interesting is this if the re tapering of the conception are removed with a blind DNC, the chances of having a recurrence and the next pregnancy goes for four times goes up four times. So this is what you need to counsel. When the patient asks you what are the chances of this happening again in the next pregnancy you have to say well the chances quite high is one in three probably. But if I remove this product under direct visualization and history A Skopje. The chances go back exponentially go down exponentially. And this gives me a power number seven that the risk of recurrence is 3.6 times higher. If the patient were treated with the n. c. as compared to history. What are the reproductive outcomes Or if these products are removed with a tissue removal system or the receptors cope. And it's basically the same. See the next pregnancy was uh achieve about at the same time the life birth of those who the retained political section were treated with the shaver or tissue retrieval system. It's a little bit better. But the placenta complications or other complications are the same. So my per number six is the reproductive outcome is probably a little bit better If the retained products are removed with the shaper or the more slater fisheries the tribal system as opposed to the using the cold blue. What are long term complications and the reproductive outcome of the patient who have retained products of conception. And this is a very important question to answer. Right? And this is because this is what really matters to the patient what's gonna happen to me after this? And this is very comprehensive systematic review. The look over Almost 340 patients and they they look they had interviewed in addition information. If the tree if the Through the routine products were removed history Aske optically it was only 30%. But if you were done with a blind DNC, the chances of interconnected information goes up to 30%. That's one in three. It's extremely high And the chances of having an incomplete evacuation of the retained product. If you do the DNC it's almost 30% that is a patient that you take to the operating room. You did you do a. D. N. C. And she continues to have the problem. That's not going to be a happy patient as opposed to if you do under direct visualization. Yes there is still a little bit of a chance that that that you have retained products but it's it's almost negligible. I want to give a word of caution because not everybody needs the routine products to be removed. And this is a very interesting article because they look at who are the patient. How can identify the patient who despite having retained products? Doesn't need Remove the history is gonna be removal. And they saw if the patient has an individual thickness less than 10. If those contents are a vascular And if this there is an absence of Miami intravascular charity one then those patients can be managed expectantly or medically and they do not need history. Skopje removal of the of the products. Another question is is it important is that we need to remove these products as soon as we diagnosed or the time from the index pregnancy until the time that we do the removal of the product has an impact subsequent of the reproductive outcome. And the answer is it doesn't really matter this. The study looked at almost 100 patients who had the Removal of the product in less than three months between 3-6 months or after six months of the index pregnancy and the electrical pregnancy outcome was exactly the same. So we don't we can reassure the patient that we can treat her expectantly. We can treat them medically. We don't need to go and remove the product as soon as they are diagnosed because it is now impact on future. And this is another very important african unfortunately. And and just giving a heads up here there is start to come my practice claims of patients who have interviewed in addition formation after D. N. C. S. For retained products of conception. And the plaintiff attorney claims that those patients are having aggressive D. N. C. S. So beware, this is my parent number seven for you to take home. Be aware of potential legal implications on performing a blind the N. C. And to conclude this this talk I want to code a very interesting code here of dr martin Friedman and will entrap them to say when we talk about international edition information. It is better to stay out of trouble, meaning prevent this from happening than to try to get out of trouble, meaning trying to solve. And and three The International Information. Once they are. Yeah I want to thank characters game for giving me the opportunity to give this talk and I'll be happy to answer any questions that you might have. Thank you. Thank you dr Kunio excellent presentation. There actually are a few questions that I'd like to ask um from the audience? Uh The first question is almost a two part is the presence of retained products of conception? A true emergency that must be addressed immediately and if not, how do you determine how soon after the diagnosis that you should perform? The history topic procedure? Well, that's that's a very interesting question and it's a question that we clinically ask ourselves all the time. Uh basically, no, it's it's not an emergency. Remember I said this is the G. Y. N. Version of retained products of conception. If you have a patient who acutely deliver and she has retained products right there in there the same day of the delivery of the following day. That's an obstetrical pathology? That is not what we're talking about here today. What we're talking about here today is the patient who has chronic retained products of conception that might have impact on future fertility. So the the first, the answer to the first part of this question will be no, it's not emergency. As long as we're talking about the chronic retain prints of protection. Right? The picture has been spotting and having this problem for a while. Now, the second question is how do I determine how quick we need to intervene? Um Well, it depends on the patient. First, depends on how bothersome the symptoms are. Is this just a light spotting that the patient can deal with or this is a symptoms that are having an impact on activity of daily living. And more importantly, is what is the future fertility of the patient? Is this a patient who has infertility and just have an early pregnancy loss? And she's interested of conceiving again the sooner the better. So that you're inclined to intervene sooner. If this is a patient who just deliver a full term baby and she does not want to conceive immediately, then you can wait a little bit longer. Thank you. Um Next question is, how do you determine who is a good candidate for an in office procedure versus someone who wanted to go to an O. R. Operating room? That's a very important question to because you want to avoid getting in trouble in an office setting, Right? Which would be more cumbersome to resolve. And what will determine that is the amount of vascular charity that this process conceptions have. If you've seen an ultrasound and the deeper interrogation of the ultrasound shows that these products have a lot of vascular charity in it like a type three, you probably will air on the side of safety and do these procedures in an operating room that will allow you to have other measures to stop the bleeding in case you run into heavy bleeding. If you see that the products are has basically no vascular charity. That is a patient that you might consider doing it in an office setting. And what do you when you do perform the procedure in the office. What's your pain management strategy? Well that's another very good question here. And this question will require an entire webinar to answer right pain management for office history as Kathy. Um what I would say here just you know to focus on retain products. Remember this is a pathology, that's a superficial pathology. These products are inside the cavity but are hardly ever attached. So the pain that the patient will feel is the same pain that you that will feel for a history Skopje polytech to me, remember what causes pain in an office setting when the patient is awake, It's entering through the cervix, distended the cavity and touching the uterine wall. So if you try to don't understand the cavity too much enter the, you know using the vagina Skopje approach and stay away from touching the diameter which you can do with retained products because again they're very superficial. This procedure shouldn't be any more painful than any other history topic polytech to me will say great and um one of the audience members was asking if you can just clarify dilatation and curettage or is it manual vacuum aspiration? What are you? Um referring to? Well it's it's the same, it's the same in dependent on the amount of products. If you're doing this in an office setting? Probably is an M. B. A. If you're taking the patient to the operating room, you will do a suction cup attached with with such an attached to a wall. I mean it depends on the amount of products that you have but basically as far as consequences are replication of the treatment, they're both the same and as a follow up is the risk of intra uterine adhesions lower with a manual vacuum aspiration compared to a. D. And C. I don't think there is data regarding answering this very question but common sense will say probably yes because the manual vacuum aspiration is more soft on the endometrium that the sharp Keret. So I'm not aware of any randomized control trial comparing both, but common sense will tell Yes, great, we do have one more question but I think it's gonna be better addressed after we hear Dr Ansari's presentation so we'll definitely come back and make sure that all questions are answered by the audience. Please continue to post your questions in the audience. We will make sure that they are answered before the end of the webinar. Thank you. Dr crew know for your time and expertise again. Um I'd like to now introduce dr Shahrazad. I'm sorry to begin her presentation. Thank you. Good day. Ladies and gentlemen, I'm dr Schar said I'm sorry from Taiwan Iran and I'm so delighted to be talking about writin productive conception and its treatment with intra uterine Bugatti shaver. Today. The term became productive conception refers to the placental of fetal tissues that remains inside the uterine cavity after an abortion, miscarriage or termination of pregnancy depending on the size vascular ization and the duration of the retaining symptoms can be different like abnormal uterine bleeding fever or mineral sub fertility. And even in some cases asymptomatic ultrasound is the first line imaging modality for the diagnosis of retained products of conception. The identification of an endometrial mass is the most sensitive finding for retained products of conception. As we know, we have four types of um within product of conception depending on Gutenberg classification from type zero which is hyper echo genic, a vascular mass to type three which is highly vascular arised mass with highly vascular system am atrium. Today I will show different operations for these four times and these are history, ascorbic patterns of return product of conception. As you can see type zero um white mass with no clear structure and type tree. It looks like a v fistula. And what are the treatment of within put out of conception First is expectant management because 80% of patients with routine product of conception will pass it by their own. And if not we can use you to return a tonic agents such as mr presto. And if none of them answered we can use surgical management which can be DNC. The traditional method or vacuum aspiration or his stra Skopje. Traditionally the surgical management of placenta remnants is the N. C. There is a but there is a higher risk of serious complications like infection at asian neutron perforation and incomplete removal and none of them are accurate. But what about history Skopje is the most accurate one. Retained products of conception are often focal and blind nature of the NC may lead to incomplete evacuation. Blind procedures such as too aggressive curettage may damage the basil labor layer of the endometrium leading to interpreter adhesion or even uh Sherman central. You can see here adhesion the incidents of inter uterine adhesions following the NCS around 20%. And this risk may increase up to 40% which is so high and repeated. D. N. C. Of which 3/4 of them have grade 2 to 4 in territory adhesion diagnosed by extra Skopje. And in this article in within in human reproduction reproduction update it shows. But what are the benefits of history landscaping within product of conception selective removing of retained productive conception. No damaging to health. The surrounding and the metric. Because you actually see the retain a low chance of incomplete removal and low complication rate. So we have different devices for removing between product conception. We have monopolized sectors go bipolar receptors, scale more simulators that among more slater's we have bigger the shaver to clear and maya. Sure through clear and my assure our disposable devices but bigger to shaver that I have experience working with. Is totally reusable and this is the I. B. S. Intra uterine, bigger to shaver. And this is the whole system of 19 French catering bigger the shape of a very simple device and totally reusable one. We have published our article of treatment of retained products of conception with dr Bugatti. In fact views and region. Um Until now I had 240 patients treated with I. B. S. And in our study I. B. S. Demonstrated a very good outcome in terms of operating time, no fluid deficit, no damage to healthy surrounding endometrium. Very easy procedure, no chance of incomplete removal and no chance of intra uterine adhesions. And now I will show you different operation with intra uterine bigotry shaver on left hand side. This is type zero team product of conception just in the austin that the access is not easy with other devices. I mean the end say you can see accurately and very easily. I removed the we can put out of conception and on the right hand side you can see type one retain put out of conception and you can see on the posterior wall easily with the aid of I. B. S. I. Removed the retain and the benefit of using I. B. S. Is that a retained productive conception is being removed at the same time of rejection. So you have perfect and clear visual fields at all time. Working with I. B. S. And here is there's a video for type to retain product of conception. As you can see in this ultrasound um image you can see the vascular charity of their retain part of conception. And again with the aid of I. B. S. I. Removed that lesion retained products of conception very neatly very precisely. And the technique that I used in this video is that I started by the pinnacle of the retained products of conception in this way this technique may help for the faster operation. And um if in case of bleeding you have finished the task. So first I have started to remove the political of the retain political conception and then uh the rest of it and the duration of operation in such a case is less than 10 minutes. And I think that I find that when using um I. B. S. Uh that the procedure is cleaner because with the sector scale we always have floating chips in the cavity. So you won't you won't have a clear visual field. But with I. B. S. As I said tissue chips are being removed at the same time of rejection. So you have perfect visual field at all times. And because of forceful irrigation so there is no blood in the cavity. So you feel won't be like japanese flag. And here you can see type three retained products of conception. And very highly vascular wise some colleagues think believe that for type two retained products of conception you should use receptor scope to stop bleeding. But as you can see here uh you can see in the ultrasound it's looked like a Vm. But it was typed three retained productive conception. Even in these cases you can use I. B. S. Intra uterine, begun shaver to remove retain productive conception. This lady um had this retained after abortion of IVF pregnancy. And after removal of this um retained productive conception after next IVF. Next next embryo transfer. She got pregnant and she has her twin Now so um the benefit of using intra uterine bigotry shaver is that you don't damage healthy surrounding endometrium because it's totally mechanical. There is no electricity. It is totally mechanical and you can do your job accurately precisely and just remove the retained. I want to share another case of retained products of conception. And this lady had unsuccessful D. N. C. You can see here by purpose the false roots. You can see the false fruit because of the N. C. That he didn't even enter the cavity. But here you can see the retained here. Um Sorry for the bad quality of the picture. This lady had bleeding and even with bleeding. I performed his Doris copy and I removed these retained and again this lady had infertility and after first embryo transfer she got pregnant And now she is on 28 weeks of pregnancy and successful pregnancy. So as you can see you can remove the retained very precise and very immediately Another case of Type three retained products of conception. As you can see they will retain girls as far as as the cirrhosis of the Uterus and the size of this retain product of conception. As you can see in this video is huge. What is the optimal size that we can use shaver For me? It was four cm even if it fills all the cavity like like in this case. But what is the key point for successful surgery? I think we should wait for 6-8 weeks until the revascularization of the retain product of conception. This waiting time after the end of pregnancy will help for less bleeding because of revascularization of your retained. In the scan that this lady had. My radiologist colleague uh told that it's a. VM. Because um it was so vascular wise and um she told me that she thought it's impossible to remove such a big and vascular arised retained by I. B. S. But we can see the end of the procedure. Now. I removed the retained with the aid of shaver. And this is the end of the operation. You can see very clear very neatly. I removed the total retained products of conception. Another case of Type three retained products of conception. And in this case you can see again uh this is six weeks after abortion and retained. This lady had one D. N. C. And as she didn't have any bleeding. So just some spotting I just told her to wait for six weeks. And then with the aid of shaver, I removed the retained and as you can see it's totally mechanical. There is no thermal injury to hold the surrounding endometrium. The resected tissue is being removed at the same time time of rejection. And very good irrigation of the shaper helps for clear visual field at all times because you exactly see what you're doing and where you are working on. And um at the end you will have perfect cavity. And I believe that for patients with infertility I. B. S. Is the choice of treatment because you will save the uterus and for further pregnancies as you can see in this video how nice and precise uh they're retained product of conception has been removed. So another case again of retained products of conception. As you can see I had bleeding. But but the good irrigation of I. B. S. Helped me to have a perfect visual field in this operation because of because the patient was under I. V. Sedation. I wanted to finish the task faster. So Um I just decided to cut the pinnacle of the returned product product of conception. And then with the aid of 4 mm grass spur which is basically a laproscopic grasshopper that we can insert through the same channel of I. B. S. To remove the rest because the yes this is the grasshopper. So sometimes for doing the job faster you can just cut the base and then Remove the dense retained product product of conception. With the aid of grasshopper like this. The total operation time was less than five minutes. And what are the advantages of I. B. S. In operation of retain product of conception resection without high frequency currents. So there is no term or injury. Less attention. Fast learning curve. Perfect visualization at all times as tissue chips are being removed at the same time of rejection In 19 French which is six out of the diameter. It is we have reduced the adaptation of Cervix. The whole system is reusable and we have it is we have reduced operation time and low complication rate. So is of use of a shaver technique and convenience of reusable blades may encourage gynecologist to turn to operative hysteria. Skopje for retain product of conception. You can use your blades for many many times. So it has cost benefit to you to operate with I. B. S. And I think I believe that we should all abandon D. N. C. For retain productive conception which is totally blind procedure And comparing to resect escape for return product product of conception which has um this like on the left hand side um learning care with the plateau to to just ameliorate your task. Um I. B. S. Has a very fast learning curve and in a couple of weeks or a couple of cases you can master it. This is exactly what happened to me. Thank you for attention and questions and comments would be most welcome. Thank you doctor around. Sorry that was an excellent presentation and demonstration of the procedure using the Bugatti shaver and scope. Um You mentioned that you want very good irrigation. Can you please explain what your setup is with a fluid pump pressure bag? What you're saying if you're using a pump what pressure settings that you're using to create a good irrigation um within the uterine cavity? Yes I I use um Hamilton and amount I have I have Hamel. Thank you. And what is your pressure setting the pressure? A bit hammer you can achieve the pressure. It depends if I have if the size of retaining is uh like three centimeter force and it was big and I have bleeding So I need more pressure for the beginning of the operation. I set the pressure like 140 a little higher in just for 12 minutes. And then just to see the exact place of the retained and then when I cut the base and be sure that there is no more bleeding I can I will decrease the pressure. 200. What fluid do you use for insulation in it? What is the intra uterine pressure set at you answered that part. But what fluid are you using? And of course bigger. Douche Where you use normal saline the are you normal saline. And are you performing these procedures in the office or in the operating room? Do you have a preference? Yeah for type for type three or two. Yes in operating theater but it's only under I. V. Sedation. So um it's not under G. A. The procedure is fast as I've shown in the videos and so it's under I visitation with sentiment and with propofol and that's it. It's um it's sort of our patient because after two hours we discharge the patient. So it's not that we admit more than that. Great. And to reduce bleeding and um fluid absorption. Do you use any inter cervical diluted patrician or vasopressin? No some everything I used trying sonic acid where the dose or one g I. V. Uh Yeah sometimes I use that but I'm not um it was depressing. You don't use it and post up do you see that? Okay you're one of my videos I showed that even quitting the pressure of the good um um irrigation systems just stopped the bleeding and just working so close to the lesion with the pressure. There was no need to use anything else. So yes sometimes just trying stomach acid at a dose of one ground. Great. And you mentioned one of your colleagues had referred a case to you thinking that a type three was an A. V. M. R. T. R. Venous malformation. How did you decide to make the distinction that it was not an A. B. M. And that it was a type three retained product of conception When you see that the medical history of the patient she had abortion and that she has this mass inside the cavity and with with even vascular charities. So it's more the diagnosis is type to retain product of conception rather than um A. BM. So when you see that this high echoing collision inside the cavity even it's when it's vascular it's and the history of the patient that she had aborted some weeks ago, it's retained rather than A. B. M. More in your radiologist likes ADM that this terminology and not for gynecologist. That's right. I'd like to invite dr kurono back as we have a few minutes left and there's a couple of questions that I'd like to understand both of your experience. Um Do you use post operative antibiotics and or estrogen? Doctor? I'm sorry. We can start with you to answer that question please. Yes I give and do you use any estrogen post operatively? It depends if it's the size of the retain is um I have a big retain part of conception. Yes. Sometimes I give estrogen for three weeks. Post operator. Can you explain your regimen for postoperative estrogen of the regiment? That is my particle. It's six million mg. Extraditable Valerie for three weeks. Thanks and dr just too late. Um Yes uh antibiotics I could use. Especially the retained products has been there for a while. You know and I suspect some endometriosis regarding the the estrogen, it depends very rarely the reason the rationale to use estrogen is to prevent interviewed in addition information. Right? Um so if the retained were very superficial and not attached and only on one side, I don't really give anything at the chances of retaining of additional intergenerational formation is really low. And at the end of the day there is no solid scientific evidence that are just support anything is saying using jail of other international edition for prevention measures, that there's nothing that really proved that prevents addition information. What's most important is adequate technique. And with the Bugatti shaver basically you barely touched the end. The media like doctor and study showed their video. I don't think about it. Um I had the same question that came through the audience. Do you perform a postoperative diagnostic flexible fiber optic hysteria Skopje 2 to 4 weeks. Post op to look for a post op film adhesion formation. That could be addressed not as a routine. No, not as routine. Sometimes when the legion paint is big use. Um At the end of the operation, yes. And I think the doctor Cronje's point there are gels, there's hyaluronic acid. Some people are looking at plasma rich protein. We've got balloons. Uh several methods in addition to estrogen and progesterone and the evidence is still um coming to fruition in the literature. So um I want to thank you both dr Cuneo and dr I'm sorry for your time, your expertise today. I thought it was an excellent webinar. I want to thank the audience for your time and your attention tape for your questions. We will have a live link available for you in a couple of weeks. Um, so please if you've had an opportunity to um I only watch a portion of this, or I want to send the webinar to colleagues as this was incredible information to disseminate. Um that link will be emailed to everybody on the call today. Um, and I want to thank you guys again for everyone's time and attention, and this concludes our webinar for this for this session. Have a great day.