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INSIDE THIS ISSUEI started working in the fascinating field of
histeroscopy in the early 80's. I was fortunate to learn from Prof.
JACQUES HAMOU his technique in micro-colpo-hysteroscopy and
micro-hysteroscopy at Port Royale Hospital and at Tenon Maternity
Hospital.
Prof. Hamou was a pioneer of modern hysteroscopy, not only for
his medical knowledge but creating the micro-colpo-hysteroscope
that allowed the visualization of the cervical transformation zone.
He also created the Hysteroflator that allowed uterine cavity
distention with CO2 and the Hysteromat currently used to distend
the uterine cavity with fluid, achieving adequate visualization
with minimal complications. He taught me how to differentiate
between hysteroscopic benign and malignant lesions and to recognize
the hysteroscopic endometrial characteristics according to the
timing of the menstrual cycle and the age of the patient. I then
created a classification based on hysteroscopic images suspicious
for malignancy with pathologic correlation that was published in J
Am Gynecol laparos in 2003 and in several specialty books.
Later I spent some time with Prof. Tantini in Florence and Prof.
Antonio Perino in Palermo, where I got the opportunity to learn
about operative hysteroscopy. With all these acquired skills and
with enough experience in the field of hysteroscopic surgery and
with the help of Professor Jacques Hamou I conducted in 1998 the
first workshop of diagnostic and therapeutic hysteroscopy in
Argentina, with the aim of spreading hysteroscopy in our country
and in Latin America. This event, with the presence of Prof. Hamou,
who performed several live surgeries, was a great success in our
country. From that year on, we have uninterruptedly organized high
quality workshops to train histeroscopists in our country and Latin
America.
Later, great teachers of hysteroscopy such as Professor
Bettocchi S. and Professor L. Mencaglia have attended several times
this workshop to show progress in hysteroscopy worldwide,
introducing in-office hysteroscopy through vaginoscopy and teaching
the benefits of surgery with the use of bipolar energy.
In 2007 we founded the Argentina Medical Society of Hysteroscopy
(SAMDHI) with the objective to disseminate and teach hysteroscopy
through courses and workshops for gynecologists across Argentina
and the rest of Latin American countries. Notably SAMDGHI is
currently affiliated to AAGL, ISGE and ESGE.
I think hysteroscopy has a prominent future in all fields this
is reflected with the wide use of hysteroscopy in modern
gynecology. I am currently focused on early detection of
endometrial carcinoma and premalignant endometriallesions in High
Risk Patients.
I would like to take this opportunity to announce the upcoming
Hysteroscopy World Congress in Barcelona where highly recognized
world leaders will confine to exchange knowledge and share their
experience in the field HYSTEROSCOPY.
FROM ARGENTINA A BIG HUG AND I WILL SEE YOU IN BARCELONA 2017
!!!!
Welcome 1
Histeroscopy Picures 2Intrauterine adhesions
Interview of the month 3Giampietro Gubbini
Original Article 6Hysteroscopic PolypectomyLaser Vs
Versapoint
Conundrums 10Hysterosalpingography
Curiosities 11Cervical Stump
Brief Review 14Sha-Levent's sign
HisteroTips 17Adenomyotic Cysts
Original Article 20Hysteroscopic PolypectomyTruclearVs
Versapoint
Jorge Enrique Dotto
Sep-Oct 2016 | vol. 2 | issue 5
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TEAM COODINATORSPAIN
L. Alonso
EDITORIAL COMMITTEE
SPAINE. Cayuela
L. Nieto
ITALYG. Gubbini
A. S. Lagan
USAJ. CarugnoL. Bradley
MEXICOJ. Alanis-Fuentes
PORTUGALJ. Metello
ARGENTINA A. M. Gonzalez
VENEZUELAJ. Jimenez
SCIENTIFIC COMMITTEEA. Tinelli (ITA)A. beda (Spa)A. Arias
(Ven)
M. Rodrigo (Spa)A. Di Spiezio Sardo (Ita)
E. de la Blanca (Spa)A. Favilli (Ita)
M. Bigozzi (Arg)S. Haimovich (Spa)
R. Lasmar (Bra)A. Garcia (USA)N. Malhotra (Ind)
J. Dotto (Arg)I. Alkatout (Ger)
R. Manchanda (Ind)M. Medvediev (Ukr)
All rights reserved. The responsibility of the signed
contributions is primarily of the authors and does not necessarily
reflect the views of the editorial
or scientific committees.
HYSTEROSCOPYPICTURES
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Under the above name I shall describe a specific type of
amenorrhea which, in spite of its prevalence, has not yet found a
fitting place and description in Gynaecological literature.
Following complicated labour or abortion a stenosis o blockage of
the internal os of the cervix may occur under certain condition,
thus producing amenorrhoea. This amenorrhoea is not funtional, but
organic; ovulation continues but the uterus do not react and the
endometrium remains in a state of inactivity. Hormonal therapy is
neither reasonable nor effective, whereas simple removal of the
blockage is sufficient to restore menstruation to normal. The
diagnosis and recognition of this type of amenorrhoea is therefore
not merely of academic interest, but it also important in practical
therapeutics.
In 1948 , Professor Joseph Asherman from TelAviv Hadassah
Hospital published the first article about the disease that bears
his name and which he defined as traumatic amenorrhea or atretic
amenorrhea. Since then, interest in this syndrome has increased
mainly due to the development of hysteroscopy and its relationship
with secondary infertility.
If you are interested in sharing your cases or have a
hysteroscopy image that you consider unique and want to share, send
it to [email protected]
Sep-Oct 2016 | vol. 2 | issue 4
Superficial vaginal endometriotic implant
Detailed aspect of the cystic area with retained blood
Detailed thin or filmy adhesion
Overview of the uterine cavity with adhesions
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INTERVIEW WITH...A life devoted to gynecology and to their
patients. His relation with hysteroscopy is summed up in three
words: enthusiasm for their work, curious to learn every day and
satisfaction to be able to transmit his knowledge to the younger
ones.
Giampietro Gubbini
Responsabile chirurgia isteroscopicaCasa di cura Pierangeli
Casa di Cura Villa Toniolo
Bolonia, Italia
Giampietro Gubbini
Responsabile chirurgia isteroscopicaCasa di cura Pierangeli
Casa di Cura Villa Toniolo
Bolonia, Italia
In 2009 he created and developed his 16 Fr Mini-resectoscope,
The Gubbini Mini Hystero-Resectoscope System
allows both, hysteroscopy and resectoscopy with reduced diameter
of
the shaft.
You have published some very interesting articles about
Isthmocele, tell us your personal experience about this topic. I
started my adventure in the world of hysteroscopy in 1981 but it
was not until 2001, when I defined as Isthmocele the lesion
(cavity) in the anterior uterine wall prodused as a result of a
caesarean section. That had already been described in the past by
various authors. I described it in a patient with secondary
infertility who after 6 months from Isthmoplasty (Isthmocele
repair) became pregnant and had a smooth pregnancy. Since then, my
series has expanded considerably and to date I have performed the
procedure in over 475 patients. The istmocele is an entity that
must be known and only then it could be diagnosed! The surgical
technique that I perform is the one proposed by Fabres in 2005,
with the difference that in addition to the initial resection of
the proximal edge of the defect I also remove the distal
endocervical margin, preserving the isthmus (endocervical
ablation), followed by targeted point-like electrocoagulation of
the uterine defect. This procedure treat the endocervical canal in
360 . (Resectoscopic correction of the "isthmocele" in women with
postmenstrual abnormal uterine bleeding and secondary infertility.
Gubbini G, Casadio P, Marra E. J Minim Invasive Gynecol. 2008
Mar-Apr;15(2):172-5.)
The resectoscopic treatment was performed in patients with
symptomatic 3rd degree isthmocele in 40% of the cases and with 2nd
degree isthmocele in 50% of the patients. In 10% of cases I had
treated patients with 1st degree isthmocele if they were candidates
for assisted reproductive technology or for the prevention of
cervical ectopic pregnancies. (Surgical hysteroscopic treatment of
cesarean-induced isthmocele in restoring fertility: prospective
study. Gubbini G, Centini G, Nascetti D, Marra E, Moncini I, Bruni
L, Petraglia F, Florio P. J Minim Invasive Gynecol. 2011
Mar-Apr;18(2):234-7.)
There was resolution of the symptoms In 90% of the 475 treated
patients. In cases of persistent symptoms, I repeated a second
procedure, followed by insertion of a Mirena IUD in women with
breakthrough bleeding. The intraoperative complications have been
low and they are more common in cases where the over-the niche free
margin was less than 3mm. In these cases, some authors recommend a
different surgical approach (laparoscopic or vaginal).
The istmocele is an entity that must be known and only then it
could be diagnosed!
Sep-Oct 2016 | vol. 2 | issue 5
http://www.vanwenstotwieg.nl/assets/files/130712_tontarra_brochure.pdfhttps://www.linkedin.com/title/responsabile-chirurgia-isteroscopica?trk=mprofile_titlefile:///vsearch/p%3Fcompany=Casa+di+cura+Pierangeli&trk=prof-exp-company-namefile:///vsearch/p%3Fcompany=Casa+di+Cura+Villa+Toniolo+BO&trk=prof-0-ovw-curr_poshttps://www.linkedin.com/title/responsabile-chirurgia-isteroscopica?trk=mprofile_titlefile:///vsearch/p%3Fcompany=Casa+di+cura+Pierangeli&trk=prof-exp-company-namefile:///vsearch/p%3Fcompany=Casa+di+Cura+Villa+Toniolo+BO&trk=prof-0-ovw-curr_pos
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www.hysteroscopy.info
It is well documented that the correction of the cesarean
induced Isthmocele restores fertility. Is the debate about
hysteroscopy and fertility over or it is just starting? The
incidence of isthmocele reported in the literature varies widely:
in a recent review, the incidence have been reported from 56 to 84%
in women undergoing caesarean section. In 10% of patients with
isthmocele may have symptoms such as abnormal uterine bleeding,
postmestrual spotting, chronic pelvic pain, dyspareunia and
infertility. This can also prevent a successful embryo transference
in cases of assisted reproductive technology. ( Hysteroscopic
treatment of the cesarean-induced isthmocele in restoring
infertility. Florio P, Filippeschi M, Moncini I, Marra E, Franchini
M, Gubbini G. Curr Opin Obstet Gynecol. 2012 Jun;24(3):180-6.)
Although some scientific societies such as the Japanese always
recommend to treat surgically with a corrective procedure, I
believe further studies are needed to demonstrate the effectiveness
of isthmoplastica repair in restoring fertility.However, I consider
important an early detection of the isthmocele and to put into
context the symptoms that these patients have, to consider it as a
late complication of cesarean birth with the aim to reduce the
cesarean section rate.
You have created a 16 Fr mini-resectoscope. Which are the main
advantajes of this tool? The continuous flow The Gubbini Mini
Hystero-Resectoscope System 16 Fr (TONTARRA Medizintechnik GmbH)
was created for "office" hysteroscopic procedures. When used with a
vaginoscopic approach it provides a quick and effectively treatment
to a wide variety of endo-uterine pathologies, using a series of
miniature loops of different types (activated and cold), evolution
of the classic resectoscopic loops, with reduced discomfort to the
patient and not requiring the use of analgesia or anaesthesia. A
large series of reusable monopolar/bipolar micro-electrodes and
cold loop with different shapes allows to perform hysteroscopic
operations with the resectoscope, making it possible to treat
quickly and effectively a variety of uterine cavity pathologies.
Moreover, the device, does not require cervical dilatation as the
traditional resectoscopic surgery does, making also possible the
treatment of endocervical disease. Finally, this tool has proved
particularly suitable for isthmocele repair, as it not requires the
use of dilators that alter the morphology of the cervical canal,
allows a more adequate evaluation and treatment. The hysteroscope
may be introduced to the uterine cavity for the treatment of
intracavitary pathologies such as endometrial polyps, uterine
septum, submucous myomas G0 e G1 (< 2,5 cm). It is important to
remember and emphasize the usual considerations regarding the
technical difficulties and the adequate indications of each
specific procedure as well as the limitations that each
hysteroscopic surgeon should arise in relation to his "learning
curve".
I believe further studies are needed to demonstrate the
effectiveness of isthmoplastica repair in restoring fertility.
Sep-Oct 2016 | vol. 2 | issue 4
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The hysteroscopic surgery with the Mini-resectoscope 16 Fr
manages to embrace most of the endo-uterine pathology traditionally
treated with resectoscopic surgery (resectoscope 26 Fr) in an
office setting using active electrodes or mechanical instruments of
5Fr. The avoidance of dilation of the cervical canal significantly
reduces the operating time. The benefits outlined in the treatment
of specific diseases in unfavorable anatomical conditions make this
tool unique in meeting the needs of the hysteroscopic surgeon.
The Oval system also now available represents the completion of
the project of mini-resector 16 Fr. The distal section to "beak
clarinet" shirts makes the use of optics for 2,9mm at 0 - 12 -30
allowing the hysteroscopic to perform more "see and treat"
procedures.
Has the hysteroscopy reached its limits?A unit of outpatient /
surgical hysteroscopy should be present in every gynecologic office
because it represents a safe and convenient way for the diagnosis
and treatment of intrauterine pathology. The future will be to
spread more and more this culture that unfortunately even today in
many countries of the world, also industrialized, is not
present.
All hysteroscopic procedures that up until a few years ago were
performed in the operating room under anesthesia with a 26 Fr
resectoscope can be now performed in 80% in an ambulatory setting
optimizing the use of health resources.
What's your vision about the learning and training in
hysteroscopy?While describing operative hysteroscopy a minimally
invasive surgery is wrong to consider it simple surgery that does
not require proper training. When in fact there could be life
treatened complications. Is therefore extremely important to follow
proper training, both at accredited schools and through popular
science journal and publications such as Hysteroscopy
Newsletter.
Do you have any advice for the young physician who is starting
in the world of gynecologic minimally invasive surgery?
Hysteroscopy should be embraced at the end of the gynecology
training and should be no room for improvisation. The old belief
that operative hysteroscopy is minor surgery is a thing of the
past. Even the simplest of actions can result in major
complications when faced with superficiality and carelessness.
The message for young people is that they should become familiar
with hysteroscopy with proper training to enable them to enjoy the
same enthusiasm, curiosity and satisfaction that even today after
so many years of practice I still have.
Hysteroscopy should be embraced at the end of the gynecology
training and should be no room for improvisation
Sep-Oct 2016 | vol. 2 | issue 5
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Outpatient hysteroscopic polypectomy: Bipolar energy system
(Versapoint) versus diode laser
Randomized clinical trialMaria D. Lara-Domnguez(1), Jose E.
Arjona-Berral(1), Rafaela Dios-Palomares(2), and Camil
Castelo-Branco(3)
(1)Department of Gynecology, Hospital Reina Sofa, Crdoba, Spain,
(2)Department of Statistics and Operational Research, University of
Crdoba, Cdoba, Spain, and (3)faculty of Medicine-University of
Barcelona, Institut Clnic of Gynecology, Obstetrics and
Neonatology, Hospital Clnic-Institut
dInvestigacions Biomdiques August Pi i Sunyer (IDIBAPS),
Barcelona, Spain
This study compares the resection of endometrial polyps using
Versapoint bipolar electrode versus Diode Laser. All procedures
were performed with a 30 Bettocchi hysteroscope, introduced by
vaginoscopy. Polyp resection in the Versapoint group was performed
using a rigid 5mm hysteroscope with a 5Fr (1.67 mm) working channel
through which a bipolar electrode was introduced that had a twizzle
tip connected to an electric generator. Polypectomy in the Diode
Laser group was performed using a rigid 6mm hysteroscope with a 7Fr
(2.3 mm) working channel through which a polyfiber was introduced
and connected to a 980 nm Biolitec Ceralas HPD laser device.
Patients were discharged after the procedure and were requested
to attend a follow-up three months later. After filling all
questionnaires, a second-look hysteroscopy was performed in order
to assess the persistence or relapse of the previous polyp.
Results
102 women were included in this study. Of these, 50 were
assigned to the Diode Laser polypectomy group, of which 46 (92.0%)
achieved a complete resection. The other 52 women were allocated to
the Versapoint bipolar electrode polypectomy group of which
complete resection was achieved in 50 (96.1%). A total of 45
(90.0%) and 46 (88.5%) women underwent the second-look hysteroscopy
in the Diode Laser and in the Versapoint group, respectively.
Most of the polyps were benign endometrial polyps. One patient
was diagnosed with a well-differentiated adenocarcinoma limited to
the polyp and another with an atypical complex hyperplastic polyp.
The mean polyp resection time with a Diode Laser was lower than
with Versapoint (245.96181.9 sec versus 329.56245.0 sec,
respectively; p=0.01). The larger the polyp size the longer the
duration of the resection (p
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Finally, incomplete resection of the polyp occurred in 4 and 2
cases in the laser and Versapoint group, respectively. Upon
second-look hysteroscopy, a relapse of the polyp in the same
location was observed in 15 (32.6%) cases in the Versapoint group,
whereas in the Diode Laser group polyp relapse was observed in only
1 (2.2%) patient (p=0.001).
To corroborate the occurrence of polyp relapse depending on the
procedure and to assess the potential effect of age on the polyp
relapse, a logistic regression was carried out using age as a
covariate. The OR estimated for the resection procedure indicates
that the likelihood of there being a relapse with Versapoint
compared with Laser is 19.2 (95% CI 2.24164.75). Of the four
patients with an incomplete resection in the Laser group, three
attended to the second-look hysteroscopy and in all of them no
polyp was observed. The fourth patient rejected the check-up due to
moving to a different city. Contrary to this, at the second-look,
the polyp persisted in the two patients of the Versapoint group who
had incomplete resection.
The rate of very satisfied patients with this outpatient
procedure tended to be higher in the Diode Laser group compared
with the Versapoint group (62.2 versus 39.1%). In addition, 71.1%
of patients in the Laser group as compared with 28.3% in the
Versapoint group referred the procedure as highly
recommendable.
Discussion
It is currently well accepted that outpatient polypectomy is
preferred by both physicians and patients when compared to one-day
hospitalization. However, there are scant data when it comes to
comparing the different instruments that are most suitable for
outpatient hysteroscopic polypectomy. To the best of our knowledge,
this is the first randomized clinical trial comparing outpatient
polypectomy using Diode Laser versus Versapoint.
The most interesting finding of the present study was the higher
percentage of patients with polyp relapses in the Versapoint group
as compared to the Laser group at three months. This may be
explained by Lasers capacity to engage with water and hemoglobin
allowing greater penetration in the soft tissues and consequently
an adequate ablation and vaporization effect. Therefore, this may
have allowed that Laser assigned patients with an incomplete
resection, subsequently eliminated the polyp three months later;
obviously, this did not occur in the Versapoint group.
Finally, patients in laser group were more prone to indicate an
improvement of their quality of life. In addition, there were a
higher number of patients in this group who felt very satisfied
with the procedure. Moreover, it is noteworthy to highlight that
three out of four patients in the Laser group reported the
procedure to be highly recommended.
In conclusion, polypectomy with Diode Laser resulted in fewer
relapses and a higher procedure satisfaction rate as compared to
Versapoint.
Panoramic view of endometrial polypEndometrial polyp as seen on
ultrasound
Hysteroscopy Newsletter
Hysteroscopy NewsletterHysteroscopy Newsletter
Sep-Oct 2016 | vol. 2 | issue 5
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DID YOU KNOW...?
Administration of vaginal misoprostol 12h before office
hysteroscopy is more effective than vaginal misoprostol 3 hours
before in relieving pain experienced by patients
When the Essure placement is difficult due to high resistance,
more time or more than two microinsert needed, a
hysterosalpingogram
should be performed.
Sep-Oct 2016 | vol. 2 | issue 4
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The Fine Art Of Hysteroscopy
Osama Shawki Sushma Deshmukh
Paras Medical PublishersYear 2014; 324 pages
The Fine Art of Hysteroscopy a must have book that offers a
global vision of the art of hysteroscopy. The known surgical vision
of Prof. Shawki combined with deep knowledge of the role of
hysteroscopy in infertility, makes this compendium a basic manual
that should not be missing in any library.
The book comes with a DVD with high quality videos that show in
detail several complete surgical procedures.
WHAT'S YOUR DIAGNOSIS?
Sometimes, when performing hysteroscopy, it is important to pay
attention to every corner of the uterus, as Vasari stated cerca
trova, he who
seeks finds
Answer to the previous issue: Detailed view of cesarean scar
defect.
Hysteroscopy Newsletter
Sep-Oct 2016 | vol. 2 | issue 5
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Hysteroscopy ConundrumsHysterosalpingogram
37 years old, 1 previous miscarriage and light period. She took
oral contraceptive pills for 6 years when she was young. Result of
the HSG.
What's your diagnosis? What to do?
Look
for u
s: hy
stero
scop
y gr
oup
in L
inke
d In
Bicornuate uterus ?
It seems a T-shaped uterus as result of maternal exposure to
DES
I'm agree with T-shaped uterus
Suspicion of T-shaped uterus. Before the hysteroscopic
metroplasty is important to have an evaluation with 3D
ultrasound.
Sep-Oct 2016 | vol. 2 | issue 4
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Curiosities: Cervical Stump Many gynecologists favor to perform
supracervical hysterectomy instead of total hysterectomy when
performed for benign conditions. Arguments used in favor of such
recommendation are that it entails less operating time, less blood
loss and faster patients postoperative recovery.
Other arguments are that preserving the cervix has positive
impact on the sexual life of the patient as well as better support
of the pelvic floor and urinary function. These last arguments seem
not to be supported by solid research evidence.
There are in fact several problems that may arise related to
preserving the cervical stump after performing a subtotal
hysterectomy. These complications include cervical stump prolapse,
chronic pelvic pain, the development of cervical or endometrial
carcinoma, necrosis of the stump and cyclic recurrent vaginal
bleeding.
In regards to cyclic bleeding, its incidence varies between
different studies between 0% and 25%, the bleeding is due to the
presence of an excessive amount of residual endometrium at the
level of the cervical stump. Although electrocoagulation of the
cervical canal is routinely done at the time of a supracervical
hysterectomy, it has not been shown that this practice
significantly reduces the incidence of persistent cyclical
bleeding.
The recommended treatment for this condition is to perform a
Trachelectomy, usually with a vaginal approach, but also it can
also be performed abdominally or laparoscopically. The vaginal
route is associated with a low complication rate, being urinary
tract injuries the most common complication.
Hysteroscopy can be useful both in locating and in treating the
residual endometrial tissue. There are papers published on
fulguration of the endometrial-endocervical tissue with bipolar
electrode system Versapoint and Spring (Pontrelli et al, 2007) as
well as with the use of a miniresector of 22FR and cutting loop
(Alonso et al, 2012). In both cases amenorrhea was immediately
achieved from the time of the intervention. Hysteroscopy should be
considered as a valid minimally invasive alternative for the
treatment of continuous cyclic bleeding related to cervical stump
after supracervical hysterectomy.
Hysteroscopy Newsletter
Hysteroscopy NewsletterHysteroscopy Newsletter
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DEVICESHYSTEROSCOPY
Hysteroscopy Endo-Operative SystemH.E.O.S (Endo-Operative
Hysteroscopy System) A new surgical system that integrates the
functions of the resectoscope and
also allows the use of mechanical and electrosurgical
laparoscopic instruments.
Equipped with a surgical channel Ch 13 (4.3 mm) allows the
insertion into the uterine cavity of monopolar instruments up to 3
mm gauge (scissors, dissectors and clamps) as well as monopolar or
bipolar electrodes. The continuous fluid flow provides
constant irrrigation ensuring optimal visualization.
These functions allow to expand the procedure performance of
hysteroscopy, limited so far to the use of the resectoscope or
employment micro-intruments through a limiting small 5 Fr (1.6 mm)
channel.
ww
w.so
pro-
com
eg.c
om/
Removal of Retained Adherent Placental Remnants Using the
Hysteroscopy Endo-Operative
System.J Minim Invasive Gynecol. 2016 Jul-Aug;23(5):670-1.
Zhu KA, Huang H, Xue M, Subedi J, Jamail G, Zhao W, Xu D, Xiao
S.
STUDY OBJECTIVE: Removal of retained adherent placental remnants
(RAPRs) may be challenging using traditional 5Fr or 7Fr
hysteroscopic grasping forceps because they are very small. This is
particularly true when the retained placental remnant is large.
This video demonstrates the advantages of using the Hysteroscopy
Endo-Operative System (HEOS), a specially designed operative
hysteroscope with a 13Fr working channel, to remove retained
placental remnants.DESIGN: Step-by-step explanation of the
technique using videos and pictures (Canadian Task Force
Classification III).SETTING: Third Xiangya Hospital of Central
South University, Hunan, China.PATIENT: A 32-year-old woman was
diagnosed with RAPRs 5 weeks after the evacuation of retained
placenta after a spontaneous abortion at 16 weeks' gestation.
Gynecologic examination revealed an anterior 8-week uterus and no
tenderness. Serum -human chorionic gonadotropin was 150 mIU/L.
Sonography revealed an irregular intrauterine mass, 3.5 cm 3.5 cm 3
cm in size.INTERVENTION: Removal of RAPRs using HEOS (Sopro-comeg
Company, Bordeaux, France).MEASUREMENT AND MAIN RESULTS: The
operation time was only 12 minutes. The RAPRs were removed
completely and quickly in 1 procedure with no complications. The
serum -human chorionic gonadotropin titer normalized 1 week after
the procedure. This study was approved by the institutional review
board of the Third Xiangya Hospital of Central South
University.CONCLUSIONS: When indicated, removal of RAPRs using HEOS
is safe and simple because of its large and strong cold forceps.
Additionally, it avoids electrical and thermal injury to the
endometrium, which is particularly important in a population that
wants to preserve fertility.
Sep-Oct 2016 | vol. 2 | issue 4
file:///G:/Hystero%20newsletter/PDF%20definitivo/Vol%202%20Issue%205/l%20%22file:///pubmed/%3Fterm=Zhu%20KA%5BAuthor%5D&cauthor=true&cauthor_uid=26872629file:///pubmed/%3Fterm=Huang%20H%5BAuthor%5D&cauthor=true&cauthor_uid=26872629file:///pubmed/%3Fterm=Xue%20M%5BAuthor%5D&cauthor=true&cauthor_uid=26872629file:///pubmed/%3Fterm=Subedi%20J%5BAuthor%5D&cauthor=true&cauthor_uid=26872629file:///pubmed/%3Fterm=Jamail%20G%5BAuthor%5D&cauthor=true&cauthor_uid=26872629file:///pubmed/%3Fterm=Zhao%20W%5BAuthor%5D&cauthor=true&cauthor_uid=26872629file:///pubmed/%3Fterm=Xu%20D%5BAuthor%5D&cauthor=true&cauthor_uid=26872629file:///pubmed/%3Fterm=Xiao%20S%5BAuthor%5D&cauthor=true&cauthor_uid=26872629
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CongresSINTERNATIONALFertility Society of Australia Annual
Conference Western Australia, Australia|Sep 4-7|2016
ESGE 25th Annual Congress Brussels, Belgium |Oct 2-5 |2016
American Society for Reproductive Medicine Annual MeetingSalt
Lake City, USA |Oct 15-19|2016
RANZCOG 2016 Annual Scientific Meeting Perth, Australia |Oct
16-19 |2016
Kongress der Deutschen Gesellschaft fr Gynkologie und
Geburtshilfe Stuttgart, Deutschland |Oct 19-22 |2016
43 International Forum. Update in Obstetrics, Gynecology and
Reproductive MedicineBarcelona, Spain | Oct 26-28| 2016
APAGE and TAMIG Annual Congress Taipei, Taiwan |Nov 3-6|2016
43 International Forum. Update in Obstetrics, Gynecology and
Reproductive MedicineBarcelona, Spain | Oct 26-28| 2016
The 24th World Congress on Controversies in Obstetrics,
Gynecology & Infertility Amsterdam, Netherlands |Nov
10-13|2016
45th AAGL Global Congress Orlando, Florida |Nov 14-18|2016
3rd International Conference on Gynecology & Obstetrics
Dubai, EAU Nov 24-26 |2016
3rd Global Congress on Hysteroscopy Barcelona, Spain May 2-5
|2017
Sep-Oct 2016 | vol. 2 | issue 5
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A septate uterus is the result of a failure in the process of
resorption of the medial septum that can range from a minimal
septum in the uterine fundus to a complete one, dividing the
uterine cavity completely or even associating double cervix and
vaginal septum
Very few studies have examined the histological features of the
septum. Since March stated that the septum is a fibroelastic
tissue, there is a widespread perception that the septum is a
structure with a small amount of muscle fibers not properly
vascularized in which the fibroelastic tissue is more prevalent.
However, this classical theory has changed after the histological
evaluation of the components of the septum. Dabirashrafi et al.
studied the amount of connective tissue, the amount of muscle and
the amount of blood vessels in different parts of the septum after
resection via Tompkins, they found less connective tissue in the
septum and an increased amount of muscle tissue and muscle
interlacing.
The vascularity of this structure has been detected with the use
of Color Doppler. With this technique Kupesic found septal
vascularity in 71,22% of the patients, revealing that most of the
septa are vascularized. Similar results were reported using
ultrasound examination in other studies.
Besides this, there are also some structural changes in the
septal endometrium when it is compared with endometrium from the
lateral uterine wall, and when endometrial samples from the septum
are examined by scanning electron microscopy, some changes
indicative of irregular differentiation and estrogenic maturation
of septal endometrial mucosa are found.
Brief Review ShaLevents Sign: A guide to determine the incision
line in the
septate uterus
Prof. Dr.Levent Yaar, Prof. Dr.Murat Ekin Bakrky Dr Sadi Konuk
Research and Teaching Hospital.stanbul.Turkey
Sep-Oct 2016 | vol. 2 | issue 4
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Hysteroscopic metroplasty is actually considered the Gold
Standar for the treatment of the septum. This tecniche is, in fact,
a transversal incision of the uterine septum instead a resection.
This incision has to be made in the middle of the septum,
equidistant to the anterior and posterior uterine walls.
Visualization of the bilateral tubal ostia is helpful to mantain
the right plane avoiding the lesion of the normal myometrium.
The determination of the correct incision line is one of the
most important part of the hysteroscopic metroplasty but this
imaginary line is not always easy to determine. Levent Yasar and
Ali Sha Snmez described the Sha-Levent sign.. After methylene blue
injection, they found a well defined blue line of 2-3 mm, over the
septum between the tubal ostiae and equidistant to the anterior and
the posterior walls. This blue guide helped them to identify the
correct incision line.
The authors have three postulations for this sign. First and the
simplest postulation is that; this appearance may be due to the
high speed jet or the turbulence of the methylene blue dye in the
top and the deepest area of uterine cavity. The second postulation
is; high metilen dye injection may lead to cracking in the mucosa
and the dye can be absorbed by the cracked zone.The third and the
last postulation is a congenital mucosal defect or a mucosal
abnormality (molecular and/or hystological) at the septum may
increase the affinity of the blue dye.
The Suha-Levent sign creates a safe hysteroscopic incision line
that facilitates the surgical approach.
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Hysteroscopy NewsletterHysteroscopy Newsletter
Illustration of inappropriate incision of uterine septum: Blue
line depicts right incision line Red lines depict inappropriate
incision line
Sep-Oct 2016 | vol. 2 | issue 5
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Congress Committee Chair: Sergio Haimovich (Spa)
CoChairs: Andrea Tinelli (Ita) Luis Alonso (Spa)
Congress Committee: Jose Alanis Fuentes (Mex) Linda Bradley
(USA) Jorge Dotto (Arg) Ricardo Lasmar (Bra) Narendra Malhotra
(Ind) Osama Shawki (Egy) Honorary Committee: Stefano Bettocchi
(Ita) Rafael Valle (USA) R. Alfonso Arias (Ven)
Sep-Oct 2016 | vol. 2 | issue 4
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HYSTEROTIPS Adenomyotic cyst is an unusual presentation, which a
lot of gynaecologists are not aware of and while there is some
literature available, detail studies are still needed to understand
this enigma.In a lot of ways it basically is Endometriotic cysts
present inside the body of the uterus and myometrium, IN behavior,
postulated theories of origin as well as management principles.
WE have recently published the largest series of
hysteroscopically diagnosed and managed Adenomyotic cysts. This is
a series of 9 cases managed hysteroscopically over a period of 8
years in 1173 hysteroscopies done.
Kuntz etal, Brosens et al, Gordts etal, Kumar et al etc to name
just a few have done work on this entity.
Here we in steps discuss the important points:
1- Definition: Adenomyosis is defined as presence of endometrial
glands and stoma in the uterine myometrium. It can be diffuse or
focal. Diffuse form is commonly seen while focal adenomyotic cyst
is a rare entity
2- Presentation: Clinical features of presentation are
non-specific. The various symptoms are dysmenorrhea, abnormal
uterine bleeding, chronic pelvic pain and infertility. Of these,
one of the most common symptoms is dysmenorrhea, which starts at an
early age, around the time of menarche, tends to increase
progressively with age and is resistant to medical therapy
including analgesics or cyclic oral contraceptives.
In our series, 77.8% of women presented with infertility and
22.2% presented with abnormal uterine bleeding.
3- Pathogenesis: One of the theories is invagination of
endometrial tissue into the myometrial tissue leading to formation
of cystic adenomyosis. Secondly, stimulation of Mullerian.remnants
in the myometrium by estrogens leads to development of adenomyotic
cyst. Lastly, iatrogenic implantation of endometrial tissue into
the myometrium during uterine surgery can also cause formation of
focal adenomyotic cyst.
Hysteroscopy Newsletter
Adenomyotic Cysts Dr. Prabha Manchanda, Dr. Rahul Manchanda, MD,
Manchanda's Endoscopic Center, New Delhi. India
Proposed by I. Brosens
Sep-Oct 2016 | vol. 2 | issue 5
https://www.facebook.com/manchandaendoscopic/
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4- Imaging techniques to diagnose: On 3 D ultrasound or MRI, it
appears as cystic structure with an internal diameter of 10 mm,
surrounded by myometrial tissue. However, adenomyotic cyst might
not be visualized on ultrasound and may appear just as a sub
endometrial hemorrhagic area, thus get missed on these techniques.
The differential diagnosis of uterine intramural cystic lesions
includes non-communicating rudimentary horn, cystic degeneration in
a leiomyoma and adenomyosis.
5- Classification System: A classification system for
adenomyotic cyst has been given by Brosens et al. He suggested the
acronym MUSCLE for its classification which includes M: myometrial
location (intramural, sub mucous, subserous), U: uterine site
(midline, paramedian, lateral), S: structure (cystic, mixed,
polypoid), C: contents (clear, hemorrhagic), L: level (fundus,
body, cervix), and E: (endometrial or inner lining endometrium,
metaplastic).
6- Hysteroscopy as a tool: Hysteroscopy is an emerging as the
gold standard diagnostic as well as therapeutic tool for submucosal
adenomyotic cyst. It is visualized as a cystic structure bulging
into the uterine cavity. Lowering the intrauterine pressure is
helpful for a better identification of the sub mucosal cystic
structures. However, when sometimes diagnostic hysteroscopy is not
able to reveal the pathognomonic signs and visible clues include:
1- Bulge in endometrial cavity. 2- An irregular endometrium with
endometrial defects. 3- Altered vascularization and 4- Cystic
hemorrhagic/ bluish lesion.
7- Resection Minutae: Hysteroscopic resection remains the gold
standard for treatment with dramatic results in cases of both
infertility and dysmenorrhea usually. Resection can be done with
scissors or by ablation methods using a loop electrode and
resectoscope. Radiofrequency ablation by radiofrequency needle
inserted into the cyst through the cervix has also been reported
For Deeper intra-myometrial adenomyotic cyst resectoscope is the
preferred choice to use. The goal is to resect the cyst in its
entirety using the same principles as in endometriosis. Ultrasound
guidance may be helpful in locating deeper adenomyotic cysts while
resecting also.
8- Conclusion: Adenomyotic cyst/ Cystic adenomyosis is a rare
form of adenomyosis the incidence of which in our study was 0.76%
over 8 years. Nowadays its incidence is increasing due to delayed
age of conception and availability of accurate imaging techniques.
Hysteroscopy is a diagnostic tool for visualization of uterine
cavity with a direct access to Adenomyotic cyst. It also allows the
simultaneous treatment of adenomyotic cyst via excision or
ablation.
It is important to make the Gynaecologist aware of such an
entity and also the hysteroscopist of the ability / power he/she
has to treat and manage this rare entity in a novel and minimally
invasive method through hysteroscopy affording much relief in
symptoms to the sufferer.
Secuence: 1- Hysteroscopic image showing elevated area on
posterior wall of uterus. 2- Hysteroscopic image showing drainage
of hemorrhagic fluid after resection with resectoscope. 3-
Hysteroscopic image showing complete excision of adenomyotic cyst
on posterior wall of uterus.
Hysteroscopy NewsletterHysteroscopy NewsletterHysteroscopy
Newsletter
Sep-Oct 2016 | vol. 2 | issue 4
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HIGHLIGHT ARTICLESPublished on different medias
OBJECTIVE: To evaluate the efficacy of a hysteroscopic
site-specific local endometrial injury (LEI) in a group of women
with unexplained infertility (UI) undergoing expectant management
with no fertility treatment versus no intervention.METHODS: This
open-label, randomized controlled trial (RCT) was conducted between
June 2013 and July 2015. Hysteroscopic site-specific LEI was
determined by patient identification number, and 120 women were
included. Eligible participants were randomly assigned to receive
either a single, site-specific LEI guided by hysteroscopy (study
group, n = 60) or no intervention (control group, n = 60). Natural
cycle folliculometry and timed intercourse were carried out for all
participants for 3 months. Successful clinical pregnancy confirmed
on ultrasound was the primary outcome measure, and first trimester
miscarriage rate was the secondary outcome.RESULTS: After
identification, baseline clinical demographics were similar in the
two groups. No statistically significant differences were noted in
cumulative pregnancy rates in women with LEI compared with those
without (16.7% and 11.7 %, respectively; OR, 2.83; 95%CI:
1.07-7.48; P = 0.4). One first trimester miscarriage was reported
in the control group (14.3%).CONCLUSION: Local endometrial injury
for natural cycle conception in women with UI is not justified.
Further RCT are warranted to prove or disprove this.
Hysteroscopic-guided local endometrial injury does not improve
natural cycle pregnancy rate in women with unexplained infertility:
Randomized controlled trial.
Shokeir T, Ebrahim M, El-Mogy H. J Obstet Gynaecol Res. 2016 Jul
[Epub ahead of print]
Reproductive Outcomes Following Hysteroscopic Resection of
Retained Products of Conception.
Ikhena DE, Bortoletto P, Lawson AK, Confino R, Marsh EE, Milad
MP, Steinberg ML, Confino E, Pavone ME.J Minim Invasive Gynecol.
2016 Jul 19.[Epub ahead of print]
STUDY OBJECTIVE: The objective of this study is to characterize
pregnancy outcomes following hysteroscopic resection of retained
products of conception (RPOC), especially as it relates to abnormal
placentation.DESIGN: Retrospective cohort study. Classification:
Canadian Task Force classification II-2 SETTING: Academic Medical
Center PATIENTS: All women who underwent hysteroscopic resection of
retained products of conception at Northwestern Prentice Women's
Hospital between January 2004 and December 2014 INTERVENTIONS:
Hysteroscopic resection of retained products of conception
MEASUREMENTS AND MAIN RESULTS: The medical records of all cases of
hysteroscopic resection of RPOCs between January 2004 and December
2014 were reviewed. Demographic characteristics, operative
findings, surgical procedure, surgical pathology and pregnancy
outcomes for preceding and subsequent pregnancies were obtained.
Our primary outcome was abnormal placentation in the pregnancy
following the procedure. There were a total of 55 subsequent
pregnancies and 38 live births. Among these pregnancies, 54.5%
(30/55) were vaginal deliveries, 34.5% (19/55) were cesarean
delivery and 7.3% (4/55) were early pregnancy loss. Abnormal
placentation was present in 18.1% (10/55) of subsequent
pregnancies. This consisted of 3 patients with placenta previa, 2
with placenta accreta and 5 with retained placenta.CONCLUSIONS:
Women who undergo hysteroscopic resection of RPOC have a higher
rate of abnormal placentation in subsequent pregnancies when
compared to the general population. Although the etiology is likely
multifactorial, the underlying pathology leading to the initial
diagnosis of RPOC is believed to play a major role.
Sep-Oct 2016 | vol. 2 | issue 5
file:///pubmed/%3Fterm=Shokeir%20T%5BAuthor%5D&cauthor=true&cauthor_uid=27363928file:///pubmed/%3Fterm=Ebrahim%20M%5BAuthor%5D&cauthor=true&cauthor_uid=27363928file:///pubmed/%3Fterm=El-Mogy%20H%5BAuthor%5D&cauthor=true&cauthor_uid=27363928file:///G:/Hystero%20newsletter/PDF%20definitivo/Vol%202%20Issue%205/l%20%22file:///pubmed/%3Fterm=Ikhena%20DE%5BAuthor%5D&cauthor=true&cauthor_uid=27449689file:///pubmed/%3Fterm=Bortoletto%20P%5BAuthor%5D&cauthor=true&cauthor_uid=27449689file:///pubmed/%3Fterm=Lawson%20AK%5BAuthor%5D&cauthor=true&cauthor_uid=27449689file:///pubmed/%3Fterm=Confino%20R%5BAuthor%5D&cauthor=true&cauthor_uid=27449689file:///pubmed/%3Fterm=Marsh%20EE%5BAuthor%5D&cauthor=true&cauthor_uid=27449689file:///pubmed/%3Fterm=Milad%20MP%5BAuthor%5D&cauthor=true&cauthor_uid=27449689file:///pubmed/%3Fterm=Steinberg%20ML%5BAuthor%5D&cauthor=true&cauthor_uid=27449689file:///pubmed/%3Fterm=Confino%20E%5BAuthor%5D&cauthor=true&cauthor_uid=27449689file:///pubmed/%3Fterm=Pavone%20ME%5BAuthor%5D&cauthor=true&cauthor_uid=27449689file:///G:/Hystero%20newsletter/PDF%20definitivo/Vol%202%20Issue%205/l%20%22
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Hysteroscopy Newsletter
Introduction Today endoscopic procedures are a fundamental part
of routine clinical practice in most surgical specialties. In
gynecology, hysteroscopy has contributed greatly to it.
The new hysteroscopic system 5.0 Truclear that offer the option
of being diagnostic and therapeutic is presented in the
gynecological market as an innovative technique. Its special design
and ease of operation in conjunction with the use of mechanical
energy for resection of intrauterine pathology, promotes efficiency
significantly increasing the number of cases that can be performed
on an outpatient basis.
ObjectivesPrimary objective: To compare the efficacy of
hysteroscope with mechanical energy (5.0 Truclear System) with
bipolar energy system (Versapoint) for the resection of endometrial
polyps.
Secondary objective: To analyze the differences betwee operating
time of both hysteroscopic techniques. To evaluate the learning
curve in each of the techniques by resident or trainees.
MethodStudy design: randomized controlled clinical trial at the
Hospital of Igualada. With inclusion period ranging from March 2013
to January 2015.
Study population: A total of 192 patients with ultrasound
diagnosis of endometrial polyp of 1 cm or larger who agreed to
participate in the study were included.
These patients were randomized into four groups according to the
hysteroscopic technique (Truclear System versus Versapoint) and the
experience of the provider performing the procedure.
ResultsThe mean age was 53.9 years. Of the total patients (n =
192), 57.8% were menopausal. 82.3% had at least one child, being
vaginal delivery the most common route of delivery in 69.3%. The
most common symptom was postmenopausal vaginal bleeding in 30.7%.
No significant differences was found in characteristics and
location of the resected polyps in the different groups. In 90% of
cases, the polyps were less than 20 millimeters in size. Pathology
of these formations confirmed the presence of polyps in 92.8% of
cases. In 2.5% of the cases some form of malignancy was present on
the polyp.
In Office Hysteroscopic Polypectomy Using Mechanical Energy. A
Comparative Study Vs Bipolar Energy Systems.
Jennifer Rovira Pampalona. Servicio de Ginecologa y Obstetricia.
Hospital de Igualada. Spain
Original Article
Sep-Oct 2016 | vol. 2 | issue 4
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Regarding how successful or effective the device was in
achieving complete polypectomy during the procedure in the Truclear
group was 92.3%, versus 73.3% in the Versapoint group (p
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FIND US ON
The endoscope, an instrument that allows to look inside the
human body, was first used in ancient Greece and Rome. As a matter
of fact, an instrument considered a prototype of endoscopes was
first found in the ruins of Pompei.
It was Philip Bozzini who, in 1805, first tried to look inside
the living human body directly through a tube he created, known as
the Lichtleiter (light guided instrument) that he first employed to
study the urinary tract, rectum and pharynx. In 1853, Antoine Jean
Desormeaux developed an instrument specially designed to examine
the urinary tract and bladder. He called it "endoscope" and it was
the first time the term endoscope was used in medicine.
Since then, the evolution has been uncontainable, the
gastrocamera was created, followed by fiberoptic scopes for
video-endoscopy and today we have capsules that once swallowed
record the entire gastro-intestinal tract.
But the endoscopic diagnosis of a disease led to the need of
minimally invasive techniques to treat them. The maximum advance in
treatment has been obtained with the creation of laparoscopy.In
1975, Dr. Tarasconi, from the Department of Obstetrics and
Gynecology, Faculty of Medicine, University of Passo Fundo (Passo
Fundo, Rio Grande do Sul, Brasil), began his experience with
laparoscopic excision of pelvic organs (salpingectomy), which he
first reported in the third congress of the AAGL, held in Atlanta
(Georgia) in November 1976. This new laparoscopic surgical
technique was subsequently published in 1981. This was the first
laparoscopic organ excision reported in the medical literature.
Since then, most resources in research and development in
endoscopy have been devoted to laparoscopy. If we look specifically
in gynecology, historically most papers and academic activity is
performed on laparoscopy. But this trend began to change in recent
years with the growing of the "little sister" of gynecologic
endoscopy, also known as hysteroscopy!
We are witnessing the development of multiple new devices,
instruments and energy sources adapted to hysteroscopy as well as
new surgical techniques that increasingly allow performing a
greater number of procedures with increase in complexity.
Hysteroscopy is today the gynecologic outpatient procedure most
commonly performed. A larger number of performed procedures leads
to an increase in diagnosis of pathology that also require
treatment which brings the concept of "see and treat", that is
becoming more prevalent in hysteroscopy.
Hysteroscopy has now reached its maturity, the number of
publications on hysteroscopy has increased exponentially in recent
years, more and more specialists dedicate their professional
activity to exclusively performing hysteroscopy. We even have an
independent publication of high level and scientific rigor with
nearly 3,000 followers, the "Hysteroscopy Newsletter".
Following the example of the natural development of endoscopy in
surgery, where different societies are organized according to their
specific interests, it is possible that the time to create an
independent hysteroscopy society has arrived.
We have the interest in hysteroscopy, we have the support of
several leaders worldwide, the starting of a dedicated journal and
even a global conference to be held in May 2017 in Barcelona. Is it
time to stop being the "little sister" of gynecologic endoscopy and
be an independent society?
The time to discuss this issue has arrived!
Sergio Haimovich
Sep-Oct 2016 | vol. 2 | issue 4