Test Your Knowledge

During RF electrosurgery with monopolar instruments:

A. The complete circuit includes the ESU, an “active” electrode, and another designed to defocus the energy 

B. Electrical current is conducted between the surgical site and the smaller area of the dispersive electrode 

C. The lower current density at the dispersive electrode site precludes tissue heating sufficient to cause a burn

D. All of the above

See Intrauterine Electrosurgery

Which of the following is/are true regarding growth and development of leiomyomas?

A. Estrogen is the gonadal steroid primarily responsible for leiomyoma growth.

B. They are monoclonal tumors of uterine smooth muscle

C. By age 50 approximately 40% of women can be demonstrated to have leiomyomas

D. They consistently demonstrate volumetric growth rates of 5-15% per year.

Leiomyomas are monoclonal tumors of uterine smooth muscle (Reference). While estrogens are likely required for the development of progesterone receptors, progesterone seems to be the gonadal steroid respoinsible for leiomyoma growth. By the age of 50, about 70% of caucasian women, and over 80% of women of African ancestry have leiomyomas (Reference). Growth rates of leiomyomas range widely with normal ranges from shrinkage to  are typically in the range of 50% over only six months (Reference).

Which of the following are true regarding the relationship of endometrial polyps and malignancy?

A. The risk of malignancy is highest in postmenopausal women.

B. Hysteroscopy but not two-dimensional transvaginal ultrasonography is a reliable predictor of malignancy in polyps

C. Tamoxifen exposure appears to decrease the risk of malignancy in endometrial polyps.

D. The addition of color Doppler imaging has dramatically increased the sensitivity of ultrasound for malignant endometrial polyps

The risk of malignancy in polyps is highest in postmenopausaly women with bleeding. This risk ranges from 1-7% depending, in part, on the age of the patient. Reference

Correct statements about bipolar instrumentation include:

A. They contain both electrodes in the circuit, essentially eliminating the patient from the circuit 

B. Compared to monopolar instrumentation, it is a less reliable method of sealing blood vessels

C. It can work well under saline in the surgical field. 

D. Thermal damage does not occur beyond the confines of the electrodes

Bipolar instruments contain both electrodes - compared with monopolar instruments where there are two separate instruments, one for each electrode - one contains the electrode designed to create the tissue effect ("active electrode") and one  designed to prevent a tissue effect, the dispersive electrode, mounted remotely from the surgical field, usually on the patient's thigh. Bipolar instruments not only work in saline media, they need electrolyte-containing media to work. 

Which of the following is/are true regarding imaging of Müllerian fusion/absorption defects?

A. 2-D transvaginal ultrasound is equally sensitive to both 3D transvaginal ultrasound and MRI.

B. MRI better depicts associated congenital anomalies of the urinary tract

C. No single imaging technique is as accurate as the combination of hysterosalpingography and laparoscopy

D. MRI is most appropriate for virginal women and those with vaginal agenesis

Reference

Which statement best describes the current role of imaging in the diagnosis of leiomyomas?

A. Ultrasound and MRI are equally sensitive for the diagnosis of leiomyomas, MRI is superior for determining size, number, and FIGO type.

B. Hysterosalpingography is the most sensitive method for characterizing submucous leiomyomas; MRI is the most accurate for size, number, and FIGO type

C. Sonohysterograpy adds little to transvaginal ultrasound for distinguishing amongst FIGO Types 0, 1, 2 and 3 leiomyomas.

D. Simple pelvic X-Ray is almost as sensitive as ultrasound or MRI for the diagnosis of leiomyomas.

Hysterosalpingography often misses submucous leiomyomas and is unsuitalble for determing FIGO Type. Sonohysterography adds substantially to ultrasound, particularly for defining FIGO type. Simple X-Ray has no utility in the diagnosis of uterine leiomyomas. MRI is superior to TVUS but is frequently equivalent to SHG. 

Which of the following is NOT a histological feature of endometrial polyps?

A. Thick walled vessels 

B. Core of irregular glands

C. Smooth muscle fibers

D. Dense stroma

Endometrial polyps contain dense stroma, endometrial glands and thick walled vessels. Should there be muscular elements, the tumor would be called a leiomyoma.

Tissue cutting or coagulation during electrosurgery is determined by:

A. The rate of heat production and the intracellular temperature 

B. The surface area of the electrode(s) near to or in contact with tissue 

C. The output current or power settings (W) on the ESU 

D. All the above

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Monopolar RF resectoscopes require:

A. Electrolyte rich distension media,

B. High viscosity distension media, 

C. Hypo-osmolar distension media,

D. Electrolyte free distension media.

Because the dispersive electrode is remote from th active electrode - the one that focuses the energy - it is important to have a medium that facilitates completion of the circuit through the uterus. If saline is used, the current would disperse and no tissue effect would occur. 

Which of the following best describes the relationship between medical therapy for leiomyomas and fertility?

A. There is no evidence that medical management of leiomyomas directly improves fertility.

B. GnRH agonists and selective progesterone receptor modulators are the only agents that have been demonstrated effective at improving fecundity.

C. Aromatase inhibitors are effective at improving fertility in women with FIGO Type 3 leiomyomas.

D. The combination of an aromatase inhibitor and GnRH agonists has been shown to improve fecundity in infertile patients.

At the present time, there is no evidence linking medical therapy to improvement in fertility.

For healthy adult women, which of the following are correct regarding the maximum allowable absorption of distending media?

A.  Normal saline 3,500 mL

B.  Electrolyte free media 1,500 mL

C. Electrolyte free media 1,000 mL

D. Normal saline 750 mL

E. Normal saline 2,500 mL

Available evidence suggests that the maximum allowable electrolyte free media should be 1.000 mL and for Normal Saline it can be 2,500. Individuals with cardiopulmonary compromise should be adjusted downward. Reference