Traditionally, endometrial sampling was not considered to be feasible in the setting of a past vaginal obliterative procedure, and thus management for such patients involved seroultrasounds or definitive treatments with hysterectomy. However, often patients opt for copolysis because of medical comorbidities or personal factors that make a more invasive surgery such as hysterectomy less desirable. Given that the lephoric copolysis maintains lateral vaginal channels, the decision was made to attempt endometrial sampling in the operating room using vaginoscopy and hysteroscopy. The objectives of this video are to describe and demonstrate approaches to endometrial sampling after a lephoric copolysis. We will describe the different modalities and instruments that can be used. We will also discuss barriers that can be encountered and describe various troubleshooting techniques. For the sake of this video, the anatomy after a copolysis will be represented with this illustration. When attempting to sample the endometrium after a lephoric copolysis, it is important to consider the potential obstacles that can be encountered. These obstacles can include a narrowed or occluded channel, acute angles required to navigate through the vaginal channels, and cervical stenosis. To overcome these obstacles, one must know the breadth of instruments and modalities that can be utilized. Hysteroscopes available come in rigid and flexible forms that are available in different diameters as shown here. It is beneficial to have the option of concurrent visual guidance with ultrasound. Both vaginal channels can be utilized to allow for a hysteroscopy guided endometrial biopsy as shown here. To do so, one would come in first with a hysteroscope to visualize the cervix, while the endometrial pipel is advanced through the contralateral channel into the cervix under direct visualization. In the event that an endometrial pipel is unable to make the acute turn into the uterus or cervical stenosis is encountered, various instruments such as the hysteroscope itself or uterine dressing forceps can serve as a backstop to guide the pipel through the cervical channel as shown here. On the day of surgery, the patient underwent an exam under anesthesia that revealed a generally atrophic vaginal canal with an obliterated midline vaginal canal consistent with the previous left forward copulclysis. On the bimanual exam, the uterus and cervix were palpable cephalodactyl to the copulclysis. The uterus was approximately five weeks size and mobile. A 2.8mm hysteroscope was advanced into the left vaginal channel, which showed a blind pouch without communication into the vaginal fornix. The tissue was grossly normal and atrophic in appearance. This prevented use of an aiding instrument as a backstop from the contralateral vaginal channel as previously described. Attention was then turned to the right vaginal channel, which showed a pillar of vaginal tissue bifurcating the channel into two additional channels. The lateral channel also ended in a blind pouch with mucinous fluid. The medial channel was further explored and the internal osseous encountered. Biopsies were taken to confirm anatomical location. To help direct through this abnormal anatomy, the hysteroscope was advanced under ultrasound guidance to help ensure we were advancing through the correct channel. A patient-guided pipel biopsy was attempted, though unsuccessful and unlikely to work due to the multiple angle changes and the inability to use the contralateral channel as a backstop. A flexible cystoscope was used in an attempt to bypass the internal os without success. At this point, frozen pathology reviewed endocervical tissue and the procedure was terminated with plans for a repeat ultrasound to assess for persistent endometrial thickening. The patient had an uneventful postoperative course, and a three-month follow-up ultrasound showed a 9mm heterogeneous endometrial stripe. The decision was made to undergo surveillance with another ultrasound in six months. The combination of cervical stenosis and an obliterated left vaginal channel made this case particularly difficult and prevented us from using one of the channels as a backstop to guide flexible instruments into the cervix. Patency of the vaginal channels are crucial to success. When attempting to sample the endometrium after a Lefort's copal clysis, be sure to have multiple modalities and aids available such as different size hysteroscopes, uterine dressing forceps, ultrasound, and an endometrial pipel. Although endometrial sampling was not successful in this case, operative endometrial sampling can be considered in the setting of a Lefort's copal clysis when the vaginal channels are patent.

endometrial sampling

lephoric copolysis

vaginal obliterative procedures

hysteroscopes

ultrasound