FERTILITY AND STERILITY VOL. 76, NO.

6, DECEMBER 2001
Copyright 2001 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.

Successful treatment of symptomatic arteriovenous malformation of the uterus using laparoscopic bipolar coagulation of uterine vessels
Yi-Cheng Wu, M.D.,a Wei-Min Liu, M.D.,a,b Chiou-Chung Yuan, M.D.,a and Heung-Tat Ng, M.D.a
Veteran General Hospital-Taipei and National Yang-Ming University, Taipei, Taiwan, Republic of China

Objective: To report a case of symptomatic arteriovenous malformation (AVM) of the uterus that was successfully treated with laparoscopic bipolar coagulation of uterine vessels. Design: Case report. Setting: University-afliated tertiary referral center. Patient(s): A 66-year-old woman with symptomatic AVM of the uterus. Intervention(s): Laparoscopic bipolar coagulation of uterine vessels. Main Outcome Measure(s): Clinical symptoms, color Doppler sonographic examination, and pelvic magnetic resonance imaging. Result(s): Remarkable shrinkage of the lesion size, obvious decrease in all of the impedance measurements (pulsatility, resistance, velocity indexes [systolic/diastolic]), and freedom from symptoms. Conclusion(s): This modality is a new alternative method for the management of patients with symptomatic AVM of the uterus who do not respond to conservative treatment. (Fertil Steril 2001;76:1270 1. 2001 by American Society for Reproductive Medicine.) Key Words: Arteriovenous malformation, uterus, laparoscopy

Received November 1, 2001; revised and accepted June 14, 2001. Reprint requests: ChiouChung Yuan, M.D., Department of Obstetrics and Gynecology, Veteran General Hospital-Taipei, 201, Section 2, Shih-Pai Road, Taipei, Taiwan, Republic of China (FAX: 886-2-28734101). a Department of Obstetrics and Gynecology. b Division of Gynecologic Laparoscopy, Department of Obstetrics and Gynecology.
0015-0282/01/$20.00 PII S0015-0282(01)02900-4

Uterine arteriovenous malformations (AVM) are uncommon, potentially life-threatening conditions (1). The primary therapeutic method for women with AVM has been embolization; however, extremely rare complications may occur, which include local pain, peripheral pulmonary or cerebral emboli, and abscess formation (2). Our patient was a postmenopausal woman with symptomatic, acquired-type uterine AVM. She was diagnosed using color Doppler ultrasound and was successfully treated using laparoscopic bipolar coagulation of the uterine vessels (LBCUV).

tory was signicant in that she had had frequent episodes of vaginal bleeding and had undergone dilatation and curettage procedures four times for intermittent vaginal bleeding and small broids since 1995. However, the specimens from the endometrium or endocervix demonstrated no remarkable ndings. The routine Papanicolaou smear test results were also normal. The mild bleeding responded poorly to p.o. methylergonovine maleate at the outpatient clinic. After this, she received a sequential regimen of hormonal replacement therapy with conjugated estrogen tablets (0.625 mg) and medroxyprogesterone (5 mg) daily. Due to heavy vaginal bleeding, she visited our institution; a transvaginal gray scale sonogram showed three posterior fundal anechoic cysts with fusiform pattern, measuring 1.8 cm, 1.3 cm, and 1.0 cm, respectively. Because of

CASE REPORT
A 66-year-old Chinese woman, gravida 4 para 4, presented with persistent lower abdominal discomfort and repeated postmenopausal vaginal bleeding. These symptoms worsened 1 month before her admission. Her obstetric his-

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the irregular-shaped cysts and the myometrium among these cysts, we performed color Doppler imaging; it revealed apparent ow reversal within these tortuous vessels. The spectral Doppler demonstrated that peak systolic velocity was 69.3 cm/second, end diastolic velocity was 44.2 cm/ second, mean velocity was 54.4 cm/second, S/D ratio was 1.57, pulsatility index (PI) was 0.465, and resistance index (RI) was 0.362. The pelvic magnetic resonance imaging showed that numerous tortuous, dilated vascular channels were present in the uterine corpus and fundus, and that they were predominantly located in the posterior wall, as well as the bilateral parametrium. After the diagnosis of AVM, our patient was admitted for laparoscopic surgery. During surgery, four ports (12, 5, 5, and 5 mm) were placed in the subumbilical area, the bilateral sides of upper abdomen, and the suprapubic area, respectively. Obviously dilated and marked tortuous pelvic vessels with pulsation including uterine vessels and ovarian vessels were demonstrated. These dilated vessels of varying sizes proceeded on the surface of the uterus and within the broad bilateral ligaments. The anterior leaf of the broad ligament was opened using laparoscopic scissors and the uterus was shifted to the opposite side to keep the peritoneum at the proper tension. We made a vertical incision of 2 to 3 cm at the triangle surrounded by the round ligament, external iliac vessels, and the infundibulopelvic ligament. To avoid intraoperative bleeding, undersized vessels enclosed in this area were coagulated using unipolar scissors. The uterine artery was isolated and desiccated using Kleppinger bipolar forceps. The procedure was performed bilaterally. After the procedure was completed, the suspensory ligament of the ovary and mesosalpinx near the uterine side was thoroughly desiccated. The whole procedure was completed within 28 minutes with minimal blood loss. One day after operation, our patient was discharged without complications. Relief of all of the AVM symptoms was achieved. At 2 and 4 months after the operation, repeat color Doppler ultrasound showed an anechoic cystic lesion of the postfundal area, measuring 14 11 14 mm, without blood ow within except for one tiny venous vessel. Spectral Doppler revealed that the peak systolic velocity was 5.35 cm/second, end diastolic velocity was 3.89 cm/second, mean velocity was 4.58 cm/second, S/D ratio was 1.38, PI was

0.328, and RI was 0.278. The second pelvic MRI demonstrated no obvious vascular channels in the uterus.

DISCUSSION
In general, AVM of the uterus is treated using surgical resection, transcatheter embolization, or both (35). For symptomatic patients with uterine AVM in whom surgical intervention is contraindicated because of age or menopause, laparoscopic bipolar coagulation of uterine vessels (LBCUV) is a viable alternative. In our patient, depletion of the blood supply to the uterus was achieved after coagulation of both the uterine arteries and the afuent blood supply from the ovarian arteries. When compared this technique with embolization, during the 12-month follow-up period we noted that our method remained unusually successful. In addition, a remarkable shrinkage of the size of the lesion, an obvious decrease in all the impedance measurements [PI, RI, VI (S/D)], and a lack of symptoms were the three major developments after this conservative laparoscopic procedure. The obvious benets of uterine artery embolization are minimal invasion, preservation of the uterus, and fewer hospitalization and recovery days. However, postembolization syndrome (massive necrosis and infarction of the uterus, uterine artery rupture, pelvic pain), transient or permanent amenorrhea, and radiation exposure are the major risks. The benets of LBCUV include relief of symptoms, shortened time of surgery, and lack of radiation exposure. The major risks of LBCUV result from general anesthesia and laparoscopic surgery. To our knowledge, this is the rst report of successful use of conservative laparoscopic surgery to treat a postmenopausal woman with symptomatic AVM of the uterus that was not treatable with conservative management. References
1. Nicholson AA, Turnbull LW, Coady AM, Guthrie K. Diagnosis and management of uterine arterio-venous malformations. Clin Radiol 1999; 54:265 69. 2. Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997;176:938 48. 3. Musa AA, Hata T, Hata K, Kitao M. Pelvic arteriovenous malformation diagnosed by color ow Doppler imaging. Am J Roentgenol 1989;152: 13112. 4. Huang MW, Muradali D, Thurston WA, Burns PN, Wilson SR. Uterine arteriovenous malformations: gray-scale and Doppler US features with MR imaging correlation. Radiology 1998;206:11523. 5. Liu WM. Laparoscopic bipolar coagulation of uterine vessels to treat symptomatic leiomyomas. J Am Assoc Gynecol Laparosc 2000;7: 1259.

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