Name: endoscopy guided photoablation of endometrial cysts using a 980 nm laser with a contact fiber in mares
Uploaded: 2020-07-16T14:30:00.000+00:00
Duration: 7 min 7 s
Description: Watch this Scientific Journal Video about Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares at JoVE.com

Authors would like to thank Mr. Pascal Lejeune for his technical support during all procedures.

The presented protocol is used for mares presented in the equine hospital and follows institutional animal care guidelines.
NOTE: Perform endometrial cysts photoablation before anestrus: heats observed in late July or August thus seem most reliable. Do not perform this procedure too late in the breeding season as it can limit the number of estruses available to treat a potential endometritis.
1. During the preceding estrus
<ol>
	<li>Perform a complete breeding soundness examination of the mare, including an endometrial biopsy1 (not described here) to ensure that the mare can potentially get pregnant after the procedure.</li>
	<li>In case of poor endometrial biopsy staging according to Kenney&#8217;s classification1, give the embryo transfer or intra cytoplasmic sperm injection (ICSI) program preference over endometrial cysts photoabalation.</li>
</ol>
2. During the preceding diestrus
<ol>
	<li>Once the rectum is empty, count, measure and map endometrial cysts of the mare in the uterus using trans-rectal ultrasonography guided by rectal palpation with a 7.5 or 5 MHz linear rectal probe and calipers on the screen (Figure 3) in a contention stock.</li>
	<li>Administer 250 &#181;g of cloprostenol intra-muscularly to induce estrus within 2 or 3 days after day 6&#8210;7 post-ovulation.</li>
	<li>On a daily basis, perform common routine ultrasonography and cervix palpation to observe estrus signs, including significant endometrial edema, antral follicle of 35 mm and softened and opened cervix.</li>
</ol>
3. Preparation when the mare is in heat
<ol>
	<li>Restrict access to the operation room to people wearing eye protection glasses.</li>
	<li>After emptying of the rectum, wrap the tail and clean the vulva aseptically using iodine-povidone.</li>
	<li>To ensure easy manipulation and comfort of the mare, administer detomidine (10 &#181;g/kg) and butorphanol (0.1 mg/kg) intravenously in the jugular vein with a 21 G needle.</li>
	<li>Per vagina, install the embryo collection catheter through the cervix and insufflate the balloon with 40 mL of air.</li>
	<li>Infuse the uterus with 1.5 L of sterile saline solution (0.9% NaCl)&#160;to inflate the uterus.</li>
	<li>Deflate the balloon and remove the catheter.</li>
	<li>Pass the endoscope aseptically through the cervix within a sterile sleeve.&#160;</li>
</ol>
4. Technique
<ol>
	<li>Connect the 600 &#181;m quartz fiber to a diode laser operating at 980 nm. Set the power at 20&#8210;25 W in continuous mode.</li>
	<li>Pass the flexible quartz fiber via the biopsy channel of a 10 mm diameter video-endoscope until 3&#8210;4 cm of free fiber can be identified on the screen. A minimum of 10 mm from the end of the fiber should be visible.</li>
	<li>Activate the laser to puncture the cyst ideally at its apex: a dedicated pedal is available on the device to keep hands free. In some cases, multiple punctures at various locations are necessary to achieve complete voiding of the cyst. The cystic fluid is passively drained out into the uterus.</li>
	<li>After the cyst lining has collapsed around the fiber, deploy the laser until the membrane shrinks.&#160;&#160;</li>
	<li>Perform transrectal ultrasonography of the uterus as many times as necessary during the procedure to confirm that endometrial cysts have disappeared.</li>
</ol>
5. Post-operative treatments
<ol>
	<li>Administer general antibiotic treatment: 22,000 UI/kg penicillin-procaine suspension, intra-muscularly, twice a day, for 3 days.</li>
	<li>Just after intervention, perform uterine lavage as described above (see steps 3.4-3.6).
	<ol>
		<li>Collect the liquid infused in the uterus before the endoscopic procedure through a sterile cuffed catheter.</li>
		<li>Flush the uterus with successive instillations of 1 L sterile isotonic solution (0.9% NaCl) until a clear liquid is collected.</li>
		<li>At the end of the procedure, administer 20 IU of oxytocin intravenously.</li>
		<li>Perform transrectal ultrasonography of the mare uterus the day after: intraluminal free liquid is frequently observed (see step 2.1).</li>
	</ol>
	</li>
	<li>As long as free intra-luminal fluid is observed by transrectal ultrasonography and until the end of the heat, perform uterine lavages daily with the procedure described above (steps 3.4-3.6). Sometimes, serum-like, limpid and yellow stained liquid is collected for several days. 
	NOTE: Giving repeated intra-muscular injections of oxytocin (20 IU) every 4 h or less when the mare is in estrus can avoid fluid accumulation and reduce the risk of bacterial contamination in the uterus.</li>
	<li>Perform trans-rectal uterine ultrasonography during the following diestrus to confirm disappearance of endometrial cysts and the absence of intraluminal free fluid. 
	NOTE:&#160;If free intraluminal fluid is observed, prostaglandin injection is recommended to induce a new estrus, to diagnose an eventual subsequent endometritis and to treat it.</li>
</ol>

<ol>
	<li>Kenney, R. M., Ganjam, V. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Selected+pathological+changes+of+the+mare+uterus+and+ovary.">Selected pathological changes of the mare uterus and ovary.</a> Journal of Reproduction and Fertility. (23), 335-339 (1975).</li><li>Bracher, V., Mathias, S., Allen, W. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Videoendoscopic+evaluation+of+the+mare's+uterus:+II.+Findings+in+subfertile+mares.">Videoendoscopic evaluation of the mare's uterus: II. Findings in subfertile mares.</a> Equine Veterinary Journal. 24 (4), 279-284 (1992).</li><li>Kaspar, B., Kahn, W., Laging, C., Leidl, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometrial+cysts+in+the+mare.+1.+Post-mortem+studies:+occurrence+and+morphology.">Endometrial cysts in the mare. 1. Post-mortem studies: occurrence and morphology.</a> Tier&#228;rztliche Praxis. 15 (2), 161-166 (1987).</li><li>Leidl, W., Kaspar, B., Kahn, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endometrial+cysts+in+the+mare.+2.+Clinical+studies:+occurrence+and+significance.">Endometrial cysts in the mare. 2. Clinical studies: occurrence and significance.</a> Tier&#228;rztliche Praxis. 15 (3), 281-289 (1987).</li><li>Mather, E. C., Refsal, K. R., Gustafsson, B. K., Seguin, B. E., Whitmore, H. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+fibre-optic+techniques+in+clinical+diagnosis+and+visual+assessment+of+experimental+intrauterine+therapy+in+mares.">The use of fibre-optic techniques in clinical diagnosis and visual assessment of experimental intrauterine therapy in mares.</a> Journal of Reproduction and Fertility. (27), 293-297 (1979).</li><li>Stanton, M. E., Mc Kinnon, A. O., Squires, E. L., Vaala, W. E., Varner, D. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Equine Reproduction Vol. 2. , 2665-2668 (2011).</li><li>Bracher, V., Mathias, S., Allen, W. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+chronic+degenerative+endometritis+(endometrosis)+on+placental+development+in+the+mare.">Influence of chronic degenerative endometritis (endometrosis) on placental development in the mare.</a> Equine Veterinary Journal. 28 (3), 180-188 (1996).</li><li>Tannus, R. J., Thun, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+endometrial+cysts+on+conception+rate+of+mares.">Influence of endometrial cysts on conception rate of mares.</a> Zentralbl Veterinarmed A. 42 (4), 275-283 (1995).</li><li>Pipers, F. S., Zent, W., Holder, R., Asbury, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonography+as+an+adjunct+to+pregnancy+assessments+in+the+mare.">Ultrasonography as an adjunct to pregnancy assessments in the mare.</a> Journal of the American Veterinary Medical Association. 184 (3), 328-334 (1984).</li><li>LeBlanc, M., Mc Kinnon, A. O., Mc Kinnon, A. O., Squires, E. L., Vaala, W. E., Varner, D. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Equine Reproduction Vol. 2. , 2620-2642 (2011).</li><li>van Ittersum, A. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+electrosurgical+treatment+of+endometrial+cysts+in+the+mare.">The electrosurgical treatment of endometrial cysts in the mare.</a> Tijdschr Diergeneeskd. 124 (21), 630-633 (1999).</li><li>Rambags, B. P., Stout, T. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcervical+endoscope-guided+emptying+of+a+transmural+uterine+cyst+in+a+mare.">Transcervical endoscope-guided emptying of a transmural uterine cyst in a mare.</a> Vet Record. 156 (21), 679-682 (2005).</li><li>Blikslager, A. T., Tate, L. P., Weinstock, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+neodymium:yttrium+aluminum+garnet+laser+irradiation+on+endometrium+and+on+endometrial+cysts+in+six+mares.">Effects of neodymium:yttrium aluminum garnet laser irradiation on endometrium and on endometrial cysts in six mares.</a> Veterinary Surgery. 22 (5), 351-356 (1993).</li><li>Bartmann, C. P., Stief, B., Schoon, H. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thermal+injury+and+wound+healing+of+the+endometrium+subsequent+to+minimally+invasive+transendoscopic+use+of+Nd:YAG-laser-and+electrosurgery+in+horses.">Thermal injury and wound healing of the endometrium subsequent to minimally invasive transendoscopic use of Nd:YAG-laser-and electrosurgery in horses.</a> Dtsch Tierarztl Wochenschr. 110 (7), 271-280 (2003).</li><li>Conley, A. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Review+of+the+reproductive+endocrinology+of+the+pregnant+and+parturient+mare.">Review of the reproductive endocrinology of the pregnant and parturient mare.</a> Theriogenology. 86 (1), 355-365 (2016).</li><li>Guzeloglu, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Expression+of+enzymes+and+receptors+of+leukotriene+pathway+genes+in+equine+endometrium+during+the+estrous+cycle+and+early+pregnancy.">Expression of enzymes and receptors of leukotriene pathway genes in equine endometrium during the estrous cycle and early pregnancy.</a> Theriogenology. 80 (2), 145-152 (2013).</li><li>Senger, P. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Pathways to pregnancy and parturition, 3rd edn. , (2015).</li></ol>

All authors are fully employed by Equine Clinic of Li&#232;ge University and have no conflicts of interest with any company trading one of the products mentioned above.

Hysteroscopy and laser photoablation of endometrial cysts is an easy procedure to reduce large intra-luminal cysts in the mare, as previously suggested14. Technically, this method is improved when performed on a mare in estrus. Inflating the uterus with sterile saline solution improved visibility when compared to air filling and continuous aspiration while performing the procedure.&#160; Small intra-parietal cysts (&#60;10 mm) are more difficult to reach and to treat. Moreover, treating these small cysts could lead to piercing of the endometrium and myometrium if laser treatment time is prolonged. However, they seldom interfere with the embryonic vesicle&#8217;s mobility and the early pregnancy diagnosis, due their localization and their size6.
Reducing numbers of intra-luminal large cysts under hysteroscopic control with the laser6 improves the mare&#8217;s annual fertility by reducing the interval between breeding and pregnancy confirmation. On day 14 post-ovulation, ultrasonographic presence of a ~14 mm diameter anechogenic embryo is used to confirm gestation, or, if it is not observed, leads to use the next heat to inseminate or breed again9,10. However, large and/or multiple endometrial cysts can delay this decision, because embryos may be hidden by endometrial cysts or confused with them6,9,10, thus limiting opportunities to get the mare pregnant, due to unexploited heats happening between two ultrasonographic controls. Hysteroscopy and laser ablation of cysts makes the day-14 pregnancy diagnosis possible again in mares that had large endometrial cysts, and thus maximizes the number of attempts, as recommended to manage difficult mares10. It also decreases the risks of an inadequate twin pregnancy diagnosis or to miss such a pregnancy.&#160;
Assessing a statistical effect of hysteroscopy and laser resection of endometrial cysts on observed fertility is very hazardous: several management factors can vary before and after surgery making comparison impossible. However, embryo migration between day 6.5 and day 16-17 could be mechanically impeded by large endometrial cysts1,4, and this incomplete uterine pregnancy recognition can lead to premature luteolysis and early pregnancy loss15,16,17. In this case of mechanical obstruction, photoablation of cysts can effectively decrease embryonic losses and improve the fertility of the mare.
However, laser resection of cysts cannot resolve the underlying causes of infertility such as endometritis or endometriosis. Response to the treatment can be disappointing when these conditions are present as they are more likely to be the cause of the poor fertility than the cysts themselves. Complete breeding soundness examination, including endometrial biopsy1,10, should be performed prior considering cyst ablation by laser in order to exclude the presence of endometrial pathologies and to define their prognosis. Any other condition compromising the mare&#8217;s fertility should be first treated, and alternatives such as embryo transfer or ICSI program should be proposed when applicable. Hysteroscopically guided endometrial cysts resection with laser is solely of interest when the endometrial cysts delay the pregnancy diagnosis or interferes with embryo migration and recognition.

Endometrial cysts in mares were histopathologically described in the seventies by Kenney1. In the late eighties, the use of hysteroscopy and ultrasonography led to their clinical description and helped to understand their consequences on fertility2,3,4,5.
In the early stages, endometrial cysts have been associated with a degeneration of the endometrium now called endometrosis1,3,4,6,7,8 and it is currently accepted that small (&#60;1 cm) cysts are related to endometrial glands fibrosis when larger cysts are related to lymphatic dilatation6. These large cysts are the most likely to disturb equine embryo migration between day 6.5 and day 17, thus decreasing the fertility by impairing maternal recognition1,3,4,6,8. Endometrial cysts may also interfere with early pregnancy diagnosis, especially if they are round and have a size similar to that of an embryonic vesicle3,4,6,9 (see Figure 1). Thus, they can potentially increase the interval between two inseminations by delaying first embryo ultrasonography and twin gestation assessment (see Figure 2). Endometrial cysts may also interfere mechanically with fluid collection during uterine lavage performed to treat endometritis or to collect the embryo. Consequently, endometrial cysts have effects on observed mare&#8217;s fertility, with potential economic consequences in breeding farms.
Besides attempts to treat the underlying endometrosis10, endoscopically-guided focal treatments of cysts have been proposed. Electrosurgical cauterization has been described, but heat exposure could injure the endometrium around the cyst11. Aspiration of the cyst is only efficient if the secreting structure is no more active at the time of the puncture12. Laser irradiation with a 980 nm diode laser with a contact fiber seems to show smaller subsequent endometrial scars6,13. Improvement of laser devices and procedures6 now allows us to propose this safe and efficient technique in equine clinical practice. However, mare owners must be informed about the limits of this option. Photoablation of the cysts will increase embryo recognition in some mares, will advance the pregnancy diagnosis in some cases and could limit the negative mechanical effect of endometrial cysts on uterine lavage performed to treat endometritis or to collect embryos. However, it will never treat the concomitant underlying endometriosis or endometritis.
This report aims to describe an efficient procedure to perform hysteroscopy-guided diode laser cyst ablation in mares. Preparation and procedures will be practically described for a clinical application.

<table><tbody><tr><td>Butorphanol</td><td>Animedica</td><td>Morphasol 10 mg/mL</td><td></td></tr><tr><td>Detomidine</td><td>Dechra</td><td>Domidine 10 mg/mL</td><td></td></tr><tr><td>Endoscope</td><td>Olympus</td><td>Vet 170-10 SN2012729</td><td></td></tr><tr><td>Endoscope Vid&amp;eacute;o Tower</td><td>Olympus</td><td>CLE-E &amp;amp; CV-E</td><td></td></tr><tr><td>Laser device</td><td>Wuhan Giga Optronics</td><td>Velas II-60B GA19-V3186</td><td></td></tr><tr><td>NaCl 0.9%</td><td>Baxter</td><td></td><td></td></tr><tr><td>P&amp;eacute;nicilline-proca&amp;iuml;ne</td><td>Kela</td><td>PENI-Kel 300.00 UI/ml</td><td></td></tr><tr><td>Ultrasonography</td><td>Aloka</td><td>Aloka 500 &amp;amp; 5mHz transrectal probe</td><td></td></tr></tbody></table>

endoscopy guided photoablation of endometrial cysts using a 980 nm laser with a contact fiber in mares

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. Historical treatments were invasive and had adverse effects on the endometrium. Hysteroscopically guided laser therapy is easy and effective for endometrial cysts resection, with no deleterious effects for the endometrium.
A 110 cm long and 1.0 cm wide endoscope is sterilely introduced in the uterus through the open cervix of an estrous mare after vulvar cleaning. The uterus is slowly infused with less than 1 L of physiologic solution and the laser fiber is inserted in the biopsy canal of the endoscope. Cysts are then cauterized with the 980 nm diode laser with a contact fiber set at 20&#8210;2 5W in continuous mode. Each cyst is punctured&#160;until complete voiding of the cyst and shrinking of the cyst wall around the fiber. Uterine lavages with sterile saline solution are performed directly after the surgery and for one or two days as non-inflammatory fluid can be observed.
This procedure is easy and quickly performed, with no obvious deleterious effects. Cysts resection makes ultrasound pregnancy diagnosis easier and, in some cases, could restore proper embryo migration in the uterine horns between day 6.5 and 17. However, this treatment does not improve the underlying histological lesions related to endometriosis. These considerations should be clearly expressed to the breeder before this procedure.

Surgeries were performed on mares having cysts with diameters over 15 mm. However, if other smaller cysts were also present, photoablation of the other cysts was attempted. Generally, these large cysts were at the bifurcation or the basis of the horns. However, some of them were present in the body of the uterus and were equally treated.&#160;
In our experience, intraluminal cysts are very easy to localize with the endoscope. Moreover, performing this procedure in saline solution increases the visibility inside the uterus: it avoids emission of vapors, foam production due to endometrial mucus and lymphatic liquid mixing.&#160; Manual closure of the cervix while maintaining and guiding the endoscope helps to keep the liquid inside. Trans-rectal manipulation of the endoscope in the uterus can sometimes help to guide the endoscope into the desired horn. Thereafter, laser intervention is quite easy and quick, with a maximum treatment time of 5 min per cyst, depending on the size and on presence of inner walls or loculations that may require multiple laser activations for the same structure. The direct contact decreased the overall temperature in the uterus. Parietal cysts were more difficult to identify, because of their localization and their smaller size (see Figure 4). In some cases, it was impossible to visualize (with the endoscope) the parietal endometrial cysts previously identified by transrectal ultrasonography. However, only the smallest parietal cysts were impossible to treat, but they do not interfere with the embryonic vesicle&#8217;s movements and are not easily confused with day-14 embryos, because of their size and localization. No direct surgical complications have been observed after the performed procedures.
Liquid accumulation was frequently observed by ultrasonography for several days after surgery. However, the collected liquid was clear and yellow and no inflammatory cells were observed on endometrial swabs. We attributed this feature to lymphatic fluid accumulation in the uterus after the opening of the cysts. Routine lavage procedures and repeated oxytocin boluses were sufficient to treat this condition before the end of estrus.
Delay between breeding and pregnancy diagnosis was shortened by decreasing the number of large size cysts. In a mare, the diagnosis was made possible again at day 14, whereas before treatment, it was only possible after day 24 or day 32 when cardiac activity or embryo migration could be respectively assessed. While laser treatment of endometrial cysts has obvious advantages, concluding about its direct effect on fertility would be dangerous, because of the many factors impacting fertility and even the birth of a foal the following season would not allow a statistically valid conclusion.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/61569/61569fig1.jpg" /> 
Figure 1: Day 14 embryonic vesicle (~14 mm diameter). Normal appearance of an embryo observed on early pregnancy diagnosis. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61569/61569fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/61569/61569fig2.jpg" /> 
Figure 2: Day 14 embryonic vesicle and endometrial cyst. The embryo (above) is attached to the endometrial cyst (below). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61569/61569fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/61569/61569fig3.jpg" /> 
Figure 3: Endometrial cysts in diestrus. Multiple cysts in the bifurcation of the horns of a non-pregnant mare (measure scale on the right side is in centimeters). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61569/61569fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/61569/61569fig4.jpg" /> 
Figure 4: Small parietal endometrial cyst. The mare is non-pregnant and in diestrus (scale bar is on the left side is in centimeters). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61569/61569fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares at JoVE.com

Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. ...

endoscopy-guided-photoablation-endometrial-cysts-using-980-nm-laser

Nanyang Technological University

Research

JoVE Journal

Medicine

4.3K Views.  Liège University. The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

Video: Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

Thermal Ablation for the Treatment of Abdominal Tumors

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ablation procedure, a thin applicator is guided into the target tumor under imaging guidance. Energy is then applied to the tissue until temperatures rise to cytotoxic levels (50-60 &deg;C). Various energy sources are available to heat biological tissues, including radiofrequency (RF) electrical current, microwaves, laser light and ultrasonic waves. Of these, RF and microwave ablation are most commonly used worldwide.
During RF ablation, alternating electrical current (~500 kHz) produces resistive heating around the interstitial electrode. Skin surface electrodes (ground pads) are used to complete the electrical circuit. RF ablation has been in use for nearly 20 years, with good results for local tumor control, extended survival and low complication rates1,2. Recent studies suggest RF ablation may be a first-line treatment option for small hepatocellular carcinoma and renal-cell carcinoma3-5. However, RF heating is hampered by local blood flow and high electrical impedance tissues (eg, lung, bone, desiccated or charred tissue)6,7. Microwaves may alleviate some of these problems by producing faster, volumetric heating8-10. To create larger or conformal ablations, multiple microwave antennas can be used simultaneously while RF electrodes require sequential operation, which limits their efficiency. Early experiences with microwave systems suggest efficacy and safety similar to, or better than RF devices11-13.
Alternatively, cryoablation freezes the target tissues to lethal levels (-20 to -40 &deg;C). Percutaneous cryoablation has been shown to be effective against RCC and many metastatic tumors, particularly colorectal cancer, in the liver14-16. Cryoablation may also be associated with less post-procedure pain and faster recovery for some indications17. Cryoablation is often contraindicated for primary liver cancer due to underlying coagulopathy and associated bleeding risks frequently seen in cirrhotic patients. In addition, sudden release of tumor cellular contents when the frozen tissue thaws can lead to a potentially serious condition known as cryoshock 16.
Thermal tumor ablation can be performed at open surgery, laparoscopy or using a percutaneous approach. When performed percutaneously, the ablation procedure relies on imaging for diagnosis, planning, applicator guidance, treatment monitoring and follow-up. Ultrasound is the most popular modality for guidance and treatment monitoring worldwide, but computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used as well. Contrast-enhanced CT or MRI are typically employed for diagnosis and follow-up imaging.

A thermal tumor ablation procedure is described. The entire procedure is detailed, including pretreatment planning and imaging studies, anesthesia, adjuvant techniques to facilitate a percutaneous approach, imaging guidance of the ablation device to the tumor, thermal treatment, post-treatment care and follow-up.

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ...

Evaluation of the Feasibility, Safety, and Accuracy of an Intraoperative High-intensity Focused Ultrasound Device for Treating Liver Metastases

Today, the only potentially curative option in patients with colorectal liver metastases is surgery. However, liver resection is feasible in less than 20% of patients. Surgery has been widely used in association with radiofrequency, cryotherapy, or microwaves to expand the number of treatments performed with a curative intent. Nevertheless, several limitations have been documented when using these techniques (i.e., a traumatic puncture of the parenchyma, a limited size of lesions, and an inability to monitor the treatment in real-time).High-intensity focused ultrasound (HIFU) technology can achieve precise ablations of biological tissues without incisions or radiation. Current HIFU devices are based on an extracorporeal approach with limited access to the liver. We have developed a HIFU device designed for intraoperative use. The use of a toroidal transducer enables an ablation rate (10 cm3&#183;min-1) higher than any other treatment and is independent of perfusion.
The feasibility, safety, and accuracy of intraoperative HIFU ablation were evaluated during an ablate-and-resect prospective study. This clinical phase I and IIa study was performed in patients undergoing hepatectomy for liver metastases. The HIFU treatment was performed on healthy tissue scheduled for resection.Liver metastases measuring less than 20 mm will be targeted during phase IIb (currently ongoing). This set-up allows the real-time evaluation of HIFU ablation while protecting participating patients from any adverse effects related to this new technique.
Fifteen patients were included in phase I&#8211;IIa and 30 HIFU ablations were safely created within 40 s and with a precision of 1&#8211;2 mm. The average dimensions of the HIFU ablations were 27.5 x 21.0 mm2, corresponding to a volume of approximately 7.5 cm3. The aim of the ongoing phase IIb is to ablate metastases of less than 20 mm in diameter with a 5 mm margin.

Here, we present an ablate-and-resect prospective study to evaluate the feasibility, safety, and accuracy of intraoperative high-intensity focused ultrasound ablation in patients undergoing hepatectomy for liver metastases.

Today, the only potentially curative option in patients with colorectal liver metastases is surgery. However, liver resection is feasible in less than 20% ...

Cancer Research

Multi-Photon Laser Ablation of Cytoplasmic Microtubule Organizing Centers in Mouse Oocytes

The fidelity of oocyte meiosis is critical for generating developmentally competent euploid eggs. In mammals, the oocyte undergoes a lengthy arrest at prophase I of the first meiotic division. After puberty and upon meiotic resumption, the nuclear membrane disassembles (nuclear envelope breakdown), and the spindle is assembled mainly at the oocyte center. Initial central spindle positioning is essential to protect against abnormal kinetochore-microtubule (MT) attachments and aneuploidy. The centrally positioned spindle migrates in a time-sensitive manner toward the cortex, and this is a necessary process to extrude a tiny polar body. In mitotic cells, spindle positioning relies on the interaction between centrosome-mediated astral MTs and the cell cortex. On the contrary, mouse oocytes lack classic centrosomes and, instead, contain numerous acentriolar MT organizing centers (MTOCs). At the metaphase I stage, mouse oocytes have two different sets of MTOCs: (1) MTOCs that are clustered and sorted to assemble spindle poles (polar MTOCs), and (2) metaphase cytoplasmic MTOCs (mcMTOCs) that remain in the cytoplasm and do not contribute directly to spindle formation but play a crucial role in regulating spindle positioning and timely spindle migration. Here, a multi-photon laser ablation method is described to selectively deplete endogenously labeled mcMTOCs in oocytes collected from Cep192-eGfp reporter mice. This method contributes to the understanding of the molecular mechanisms underlying spindle positioning and migration in mammalian oocytes.

An optimized protocol is presented that enables the depletion of cytoplasmic microtubule organizing centers in mouse oocytes during metaphase I using a near-infrared femtosecond laser.

The fidelity of oocyte meiosis is critical for generating developmentally competent euploid eggs. In mammals, the oocyte undergoes a lengthy arrest at ...

Developmental Biology

Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser

The occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem with a high incidence in the aging male population. Although it is not a life-threatening disease, BPH causes problems that seriously impact the quality of life. Here, we introduce a new technique called photoselective vaporesection of the prostate (PVRP) in treating BPH, which can be seen as a variation of photoselective vaporization of the prostate (PVP). This procedure presents several advantages compared to the PVP technique including less laser energy loss, less intraoperative complications as well as more tissue resection rate.

Here we present a protocol to perform Photoselective Vaporesection of the Prostate (PVRP) for benign prostatic hyperplasia (BPH) treatment.

The occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem with a high incidence in the aging ...

Enucleation of the Prostate for the Treatment of Benign Prostatic Hyperplasia Using a 980 nm Diode Laser

In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. Here, we introduce a new technique called 980 nm diode laser enucleation (DiLEP) to treat BPH1. Diode lasers can absorb both water and hemoglobin at the same time, so they are good for cutting and hemostasis2. The diode laser was approved by the FDA in 2007, and has been used in the treatment of BPH because of its effective cutting and hemostasis effect3. DiLEP presents several advantages over other techniques, such as TURP, HoLEP, and PVP. During the procedure, we define the boundary of a high-volume prostate and separate it into three lobes with a diode laser by burning two rings and one groove (like a Cupid&#39;s arrow). Compared to other procedures, mDiLEP has fewer intraoperative complications, a shorter learning curve, and achieves more tissue resection.

Here, we present a protocol for modified 980 nm diode laser enucleation to treat large volume benign prostatic hyperplasia.

In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. ...

Development of a Noninvasive, Laser-Assisted Experimental Model of Corneal Endothelial Cell Loss

Nd:YAG lasers have been used to perform noninvasive intraocular surgery, such as capsulotomy for several decades now. The incisive effect relies on the optical breakdown at the laser focus. Acoustic shock waves and cavitation bubbles are generated, causing tissue rupture. Bubble sizes and pressure amplitudes vary with pulse energy and position of the focal point. In this study, enucleated porcine eyes were positioned in front of a commercially available Nd:YAG laser. Variable pulse energies as well as different positions of the focal spots posterior to the cornea were tested. Resulting lesions were evaluated by two-photon microscopy and histology to determine the best parameters for an exclusive detachment of corneal endothelial cells (CEC) with minimum collateral damage. The advantages of this method are the precise ablation of CEC, reduced collateral damage, and above all, the non-contact treatment.

Here, we present a protocol to detach corneal endothelial cells (CEC) from Descemet&#8217;s membrane (DM) using a neodymium:YAG (Nd:YAG) laser as an ex vivo disease model for bullous keratopathy (BK).

Nd:YAG lasers have been used to perform noninvasive intraocular surgery, such as capsulotomy for several decades now. The incisive effect relies on the ...

Focal Laser Ablation of Prostate Cancer: An Office Procedure

In this article, we describe and illustrate an outpatient procedure for focal laser ablation (FLA) of prostate cancer (PCa). The procedure is conceptually similar to a fusion biopsy and is performed under local anesthesia in a clinic setting; treatment time is usually less than one hour. Laser insertion is guided by ultrasound; lesion targeting is via magnetic resonance imaging-ultrasound (MRI/US) fusion, as in targeted prostate biopsy. Real-time ablation monitoring is achieved utilizing a thermal probe adjacent to the laser fiber. The video demonstrates procedure planning, patient preparation, various steps during the procedure, and treatment monitoring. Safety, feasibility, and efficacy of this approach have been established during a previous trial. Outpatient FLA under local anesthesia is an option for management of intermediate risk prostate cancer.

This article presents and describes an outpatient treatment for prostate cancer using focal laser ablation. Laser catheter placement is guided by MRI-ultrasound fusion imaging in a fashion similar to prostate needle biopsy. Treatment is monitored in real-time with a thermal probe, placed adjacent to the laser fiber.

In this article, we describe and illustrate an outpatient procedure for focal laser ablation (FLA) of prostate cancer (PCa). The procedure is conceptually ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated with a potential reduction in the ovarian reserve due to the inadvertent removal and thermal damage of healthy ovarian tissue. New ablative techniques with reduced tissue penetration depth and less thermal spread to the surrounding parenchyma may represent a viable alternative to cystectomy. For these reasons, the aim of this manuscript is to demonstrate the ablation of the endometrioma capsule using a CO2 fiber laser technique and discuss the clinical outcomes. Once the cyst has been drained and washed, a biopsy is taken. After cyst eversion, vaporization of the inner surface of the cyst is performed using a CO2 fiber laser. The technique is simple and reproducible as even young surgeons without any surgical experience were more confident in performing laser CO2 vaporization instead of cystectomy. The positive effects of CO2 technology are reported in a randomized controlled trial, where the postoperative changes in the antral follicular count (AFC) and antimullerian hormone (AMH) levels were compared between patients who had their endometrioma excised (cystectomy) and those who had undergone endometrioma vaporization with CO2 laser. The patients treated with CO2 laser showed significantly increased AFC without a reduction in serum AMH levels as compared to the cystectomy group, in which both parameters were significantly reduced. The postoperative pregnancy rate was also assessed, and comparable pregnancy rates were found after both treatments. On the contrary, patients treated with the CO2 fiber laser technique had more favorable in-vitro fertilization (IVF) outcomes compared to cystectomy.
In conclusion, the CO2 fiber laser technique may represent a viable alternative to cystectomy in the surgical treatment of endometrioma in terms of ovarian preservation, pregnancy rates, and IVF outcomes. Moreover, it has the advantage of being independent of the surgeon's skills and personal experience.

In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated ...

Hysteroscopic Technique with Micro-Scissors and Forceps for Polyp Removal

Improved Hysteroscopic Resection of Endometrial Polyps Using 6-Fr Micro-Scissors and Forceps

Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. Numerous resection methods are available, with the most used and cost-effective options being cold resection employing micro-scissors or hot resection using an electric loop. However, both methods involve sharp resection, posing a challenge in achieving complete polyp removal while avoiding damage to the uterine endometrium. To address this issue, this study proposes an innovative approach: the combined use of the 6 Fr micro-scissors and forceps under hysteroscopy. The method entails utilizing 6 Fr micro-scissors to initially remove large polyps, followed by using 6 Fr micro-forceps to extract the remaining polyp tissue expeditiously and bluntly near the basal layer of the endometrium. This approach not only prevents surgical damage to the basal layer of the endometrium but also mitigates the risk of residual polyps resulting from incomplete resection. This method is particularly suitable for women with fertility requirements, offering additional considerations for the selection of treatment options for endometrial polyp resection.

Author Spotlight: A Reproductive Hysteroscopy Approach for Complete Endometrial Polyp Removal and Enhanced Endometrial Receptivity

The novel technique presented here employs a combination of 6-Fr micro-scissors and forceps for hysteroscopic treatment of endometrial polyps, demonstrating encouraging outcomes for infertile patients afflicted with this condition.

Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. ...