Effectiveness of Outpatient Versus Operating Room Hysteroscopy for the Diagnosis and Treatment of Uterine Conditions: A Systematic Review and Meta-Analysis.

Abstract

Traditionally, hysteroscopy has been performed in the main operating room with the patient under general anaesthesia. Hysteroscopy performed in an office setting avoids the risks of general anaesthesia. The aim of this review was to evaluate the effectiveness of outpatient hysteroscopy compared with hysteroscopy performed in the operating room to diagnose and/or treat intrauterine pathology. Relevant electronic databases were searched, including Medline, EMBASE, and the Cochrane Library. RCTs and nonrandomized studies that compared the efficacy of outpatient hysteroscopy and traditional hysteroscopy performed in the operating room were included. The primary outcome of interest was diagnostic accuracy, and secondary outcomes included treatment success, adverse events, pain, patient satisfaction, and cost. The Cochrane risk of bias tool was used to assess RCTs, and the Downs and Black tool was used for nonrandomized studies. A total of 12658 abstracts and 347 full-text articles were assessed, from which a total of 20 full-text studies met our eligibility criteria. No study compared the diagnostic accuracy of outpatient hysteroscopy with hysteroscopy performed in the operating room. There was no significant difference between hysteroscopy performed in the outpatient and operating room setting for treatment success, adverse events, and patient satisfaction. In the included RCTs, there was greater reported postoperative pain in the outpatient setting (standard mean difference 0.19, 95% CI 0.01-0.37). All seven economic studies concluded that outpatient hysteroscopy (range US$97-1258) is substantially less expensive than hysteroscopy performed in the operating room (range US$258-3144). Included RCTs had serious risks of selection, performance, and detection bias. The results of this review demonstrate that implementing hysteroscopy in an outpatient setting without general anaesthesia should be thoughtfully considered. The current available evidence demonstrates greater reported postoperative pain in the outpatient setting and no statistically significant differences in all other studied outcome measures between outpatient and intraoperative hysteroscopy procedures.