P-445: Is there a threshold diameter of endometrial polyps for hysteroscopic removal at the office setting in the absence of anesthesia or analgesia?

Abstract

Office hysteroscopy has enabled the gynecologists not only to perform targeted hysteroscopic biopsies but also treat benign intrauterine pathologies such as polyps without any analgesia and anesthesia. Administration of anesthesia in the office setting increases the costs and morbidity. The vaginoscopic approach (without speculum or tenaculum) has minimized patient discomfort related to the traditional hysteroscopic access into the uterus. Retrospective chart review in a university based hospital. We reviewed the surgery charts of 825 patients who underwent office hysteroscopy between May 2003 and April 2006. We excluded 23 patients with severe endocervical stenosis who required sedation and analgesia. Hysteroscopy was performed using a continuous flow5-mm operative office hysteroscope (Karl Storz, Tuttlingen, Germany) without any anesthesia. To avoid discomfort or pain for the patients, the transvaginal approach was used without speculum and tenaculum. Distension of the uterine cavity was obtained using normal saline solution and the intrauterine pressure was automatically controlled by an electronic irrigation and suction device (Endomat, Karl Storz, Tuttlingen, Germany). The intrauterine pressure was set at 45 mm Hg, being the balance of an irrigation flow around 200 mL/minute and a vacuum of 0.2 bars. Solely being an outpatient clinic procedure, office hysteroscopy was performed in the patients without any medication, local or general anesthesia to reduce pain or discomfort. If a polyp could not be removed, the patient was scheduled to undergo a 9 mm operative hysteroscopy with resectoscope under general anesthesia (Karl Storz, Tuttlingen, Germany). The mean age of the patients was 43.6 years ±13.0 (20-80). In 184 patients (94.8%) endometrial polyps were successfully removed by office hysteroscopy (mean duration: 10.0±2.79 (5-18) min and visual analog scale score -VAS-: 1.54 ±0.7). However, in 10 patients (5.1%) endometrial polyps did not completely removed by office hysteroscopy (mean duration: 20.9±3.5 (16-26) min; VAS: 4.1±1.8). The major reason to switch to resectoscopic surgery is intolerable pelvic pain and patient request to terminate the surgery. The mean diameters of the endometrial polyps those were removed by office hysteroscopy and resectoscopy were 13.6±7.79 (3-40), and 33.3±6.24 (20-40mm), respectively. The threshold diameter of endometrial polyps which are likely to be removed by office hysteroscopy was found to be 25 mm by receiver operating characteristic (ROC) analysis. 12 of 21 patients with polyps >25 mm in diameter could be successfully managed by office hysteroscopy. While parity, or menopausal state were not the determinants of the failed polypectomy, the durations of procedures in failed and successful attempts were significantly different (21.4 ±3.2 min vs 16.2 ± 1.5 min, respectively; p=0.13). Gynecologists may remove polyps <25 mm in diameter safely using office hysteroscopy with scissors without giving anesthesia or analgesia. In this way, this is the most economical option. In presence of larger polyps, other alternatives such as bipolar vaporization, addition of sedation/anesthesia or resectoscope may be considered in expense of the increased costs. Polyp removal should be completed in 15 minutes for better patient tolerance.