Combined hysteroscopy-laparoscopy approach for excision of pelvic nitinol fragment from Essure contraceptive device: Role of intraoperative fluoroscopy for uterine conservation

Abstract

We describe the successful removal of a pelvic contraceptive coil in a symptomatic 46-year-old patient who had Essure devices for four years, using a combined hysteroscopy-laparoscopy-fluoroscopy approach. Following normal hysteroscopy, at laparoscopy the right Essure implant was disrupted and its outer nitinol coil had perforated the fallopian tube. However, the inner rod (containing polyethylene terephthalate) had migrated to an extrapelvic location, near the proximal colon. In contrast, the left implant was situated within the corresponding tube. Intraoperative fluoroscopy was used to confirm complete removal of the device, which was further verified by postoperative computed tomography. The patient's condition improved after surgery and she continues to do well. This is the first report to describe this technique in managing Essure complications remote from time of insertion. Our case highlights the value and limitations of preoperative and intraoperative imaging to map Essure fragment location before surgery.

Challenges in Removing the Essure® Device

“…Few case-reports about the removal of the fourth marker are published. [ 8 , 9 ] This is, by our knowledge, the first report written about fragmentation of the third marker. Until now, it was not recognized that the third marker could also be teared off during removal surgery.…”

“…Intraoperative fluoroscopy is described in previous case reports to find lost fragments of the insert. [ 8 , 11 ] It is a challenge to localize the exact localization of the fragment. Even with fluoroscopy, technical skills are needed for the removal.…”

“…However, also bilateral salpingectomy is a common approach for Essure ® removal. [ 8 ] If gynecologists understand the structure and function of the device, it is possible and feasible to perform nonhysterectomy removal. This reduces the risk of complications during and after surgery and the duration of the operation and recovery time.…”