I would like to commend the authors of the article, “Resectoscopic treatment combined with sonohysterographic evaluation of women with postmenstrual bleeding as a result of previous cesarean delivery scar defects,” for an excellent paper describing the diagnosis and treatment of an unusual problem. I am hoping, however, that the description of using “sterile water” as to distend the uterus is a typographical error.

Excess absorption of distending media is a known and common complication of hysteroscopic surgery. Absorption of plain water, without any osmotically active particles, can cause severe hemolysis. For this reason water was abandoned for urologic resectoscopic surgery decades ago.

Because nonconductive solutions must be used with monopolar energy, all solutions designed for monopolar resectoscopic surgery have osmotically active nonelectrolytic compounds added, such as glycine, mannitol, or sorbitol. Absorption of hypotonic fluid has caused hyponatremia, and cerebral edema, resulting in permanent neurological damage or death. Absorption of isotonic solutions such as 5% mannitol can cause hyponatremia but do not cause the hypoosmolality associated with cerebral edema and are preferred when a monopolar resectoscope is used. The use of water as a distention medium can cause serious complications is absolutely contraindicated.