To prove the effectiveness of the Shaver technique in the treatment of multiple polyps and hyperplasia even when induced by prolonged Tamoxifen therapy.

Study Objective: To prove the effectiveness of the Shaver technique for multiple polyps and hyperplasia treatment, even when induced by prolonged Tamoxifen therapy.

Design: Descriptions of the surgical steps and prognosis according to a case report

Setting: “SELEC Sino European Life Expert Centre” of Jiao Tong University, Shanghai

Patient: A 45-year-old nullipara woman with a medical history of one abortion. In June 2021 she was diagnosed with stage IIA breast ductal cancer. She underwent a radical unilateral mastectomy in July 2021. After 20 cycles of adjuvant radiotherapy, 20mg of Tamoxifen, per os daily, was administrated. The patient reported no more menstrual period after radiotherapy and every three months after the operation she underwent a careful follow-up with pelvic examination and transvaginal ultrasound. After one year of therapy the patient developed abnormal uterine bleeding and during the scheduled check, an endometrial thickness of 12 mm was reported. To exclude the presence of malignancy a diagnostic hysteroscopy with histological evaluation was planned. The result showed the presence of a simple non atypical polypoid hyperplasia and therefore an operative hysteroscopy was planned.

Intervention: The operative hysteroscopy was performed with the Intrauterine Bigatti Shaver (IBS®). The Shaver 24Fr optical system with the SA blade was used. The rotation rate of the blade was 2100 rotations per minute (rpm) with a suction flow of 250 ml per minute. As it was reported during diagnostic hysteroscopy, the uterine cavity showed the presence of a polypoid hyperplastic endometrium. The Shaver SA blade was able to remove all the multiple polyps together with the related hyperplastic endometrium in a very short time. A perfect uterine cavity with a regular endometrial surface was restored. No intra-operatory bleeding was reported and a perfect vision was maintained during the whole procedure. The operative hysteroscopy lasted about 3 minutes without any intraoperative complications. To prevent adhesion formation a Materegen gel by Bioregen was left in place at the end of the procedure. The patient was discharged from the hospital two hours after the operation.

Main Result: The histological exam confirmed the previous benign endometrial biopsy result. Following patient consultation, it was decided to continue with the Tamoxifen therapy subject to strict follow-up with regular checks and ultrasound every 3 months according to our Renji Hospital Guidelines.

Conclusion: The use of the shaver technique has already proven to be the best choice to remove polyps and hyperplastic endometrium. In a randomized control study, published by Bigatti et al. (2011), it has been shown that the time of the procedure, the fluid deficit and the learning curve for the surgeon is statistically significant better for the shaver technique compared to bipolar resection. Also, for all types of myomas including G1 and G2, the shaver technique has proven to be a valid alternative to resection if the size is less than 3 cm in diameter. In another retrospective study always by Bigatti et al (2013) it has been proven that almost 93.5% of myomas less than 3 cm could be removed with the shaver technique in a single step procedure and 62.5% of these were G2 myomas. In addition, in an ongoing retrospective study on 1000 shaver polypectomies and endometrial resection at the SELEC of Shanghai we have found that the recurrence rate is only 0.3%. After 12 months from the original surgical procedure only 3 patients developed polyps and hyperplastic endometrium. The shaver technique is able remove the endometrial functional layer without affecting the basal layer. This new technique acts like a normal D&C under vision, reducing the risk of complications. The use of the shaver technique in case of Tamoxifen induced hyperplasia has an additional advantage of reducing the risk of postsurgical adhesions. In case of prolonged Tamoxifen treatment, the presence of a normal uterine cavity will allow the possibility to early detect a malignant evolution of the endometrial layer. This case report shows that the Shaver technique for multiple polyps, with or without hyperplasia, even when Tamoxifen induced, should be the treatment of choice. The Shaver technique can remove all the hyperplastic endometrium of the uterine cavity in a very easy, fast, clear, safe and precise way as it is shown in our video. The Bigatti Shaver technique allows to perform a Visual D&C procedure, improving the quality of the result and reducing the risk of complications.