Transvaginal Ultrasound Guided vs Laparoscopic Ethanol Sclerotherapy; Techniques, Tips & Tricks.

Abstract

Study objective: To present and compare transvaginal ultrasound guided versus laparoscopic ethanol sclerotherapy (EST) techniques.

Design: Step-by-step video demonstration of both sclerotherapy techniques.

Setting: A university hospital's reproductive health and research centre.

Patient(s): 1. Patient with bilateral large endometriomas and infertility. 2. Patient with symptomatic endometriosis and a large endometrioma wishing to conceive naturally.

Intervention(s): Transvaginal ultrasound guided EST can be performed with local anesthesia/sedation or general anesthesia (1). Following vaginal iodine cleansing and antibiotic prophylaxis, endometrioma is punctured once with a single lumen 15-16-gauge needle and aspirated. The needle is held steadily until the end of the procedure to prevent leakage of contents or alcohol. Then the cyst cavity is flushed until the irrigation fluid becomes completely clear. Ethanol, equal to 60% of the aspirated cyst volume, is injected, and totally aspirated 10 minutes later (2-4). In case of laparoscopic EST, the endometrioma is punctured directly with ipsilateral 5 mm trocar and the cyst contents are aspirated. The cyst cavity is flushed and a 14F Foley catheter is placed to suspend the cyst and prevent alcohol leakage. Then, the cyst cavity is filled with ethanol which is totally aspirated after 10 minutes (2-5). Following catheter removal, excise the cyst portion not exposed to ethanol and assess inner surface of the cyst. After the steps, the operation is continued with other surgeries.

Main result(s): A video presenting transvaginal EST in preparation for IVF and laparoscopic EST during endometriosis surgery.

Conclusion(s): Both transvaginal and laparoscopic ethanol sclerotherapy are effective, minimally invasive, and cost-efficient techniques. In any fertility situation where preventing damage to the tubal mucosa is important (due to the possibility of leaked alcohol damaging the tubes and causing peritoneal adhesions), where a biopsy of the cyst is needed, there is difficult access to the pouch/ovaries, or other pathology needs to be treated, we prefer a laparoscopic approach.