Office Hysteroscopies Research Articles

Outpatient hysteroscopy: Suitable for all? A retrospective cohort study of safety, success and acceptability in Australia.

In Australia, gynaecologists continue to assess and investigate abnormal uterine bleeding with inpatient hysteroscopy despite evidence validating outpatient hysteroscopy services. This retrospective cohort study assessed the safety, success and acceptability of office hysteroscopy in a gynae-oncology rapid-access clinic over six years in Sydney, Australia, and included all women without an age or body mass index (BMI) cut-off using a 'see and treat' concept. A database was created and analysed retrospectively for patients who attended office hysteroscopy service between January 2016 and March 2021 (63 months, 481 eligible). An anonymous modified PAT-32 patient satisfaction questionnaire was also offered to an initial cohort after their procedure to gauge insightful feedback about acceptability. A total of 92% of patients had successful outpatient hysteroscopic access; 24% of cases required hysteroscopy under general anaesthesia (GA) despite pathology in over 50% of cases; 68% of the total were able to be managed with outpatient hysteroscopy and did not require a follow-up GA hysteroscopy. This paper is also the first of its kind to our knowledge to incorporate patients >65 years, those with a BMI >35 and those with a history of cervical stenosis. This study suggests that age and BMI do not impact the success rate of the procedure. This study demonstrates that outpatient hysteroscopy is an acceptable, safe procedure that is well tolerated by patients. Considering our rapid-access hysteroscopy service allowed 68% of the patient cohort to avoid hysteroscopy under GA, we estimate conservatively ~$63 million per year in Australia could be saved by performing office hysteroscopies.

Hysteroscopic versus histopathological agreement in the diagnosis of chronic endometritis: results from a retrospective observational study

PurposeTo evaluate the agreement rate between hysteroscopy and pathological examination in case of chronic endometritis.MethodsA retrospective observational study carried out at Gynecology and Obstetrics Department, Puerta de Hierro Hospital, Autónoma University of Madrid, Spain, from January 2021 to June 2022 was performed by obtaining data from 115 medical records of women who underwent office hysteroscopies that was compared with the findings of final histological examination of endometrial biopsy. Cohen's kappa index was used to evaluate this agreement rate. In addition, sensitivity, specificity, positive and negative predictive value and diagnostic accuracy were obtained.ResultsThe agreement between hysteroscopic findings and histological examination showed a modest result with a Cohen’s kappa index of 34%. In addition, we obtained a specificity of 70% and a sensitivity of 64%. The positive and negative predictive value were 60.8% and 73.4%, respectively. An excellent agreement rate (100%) between histological and hysteroscopic results was observed in presence of hyperemia and micropolyps.ConclusionAlthough the sample size is not as large as that of other studies published so far, the first glance of our experience is that hysteroscopic signs are not yet sufficient to make an accurate diagnosis of chronic endometritis, thus requiring a histopathological confirmation to make it.

Predictive Factors of Tolerance in Office Hysteroscopy - a 3-Year Analysis from a Tertiary Center.

Pain is the primary limitation to performing hysteroscopy. We aimed to evaluate the predictive factors of low tolerance to office hysteroscopic procedures. Retrospective cohort study of the patients who underwent office hysteroscopy from January 2018 to December 2020 at a tertiary care center. Pain tolerance to office-based hysteroscopy was subjectively assessed by the operator as terrible, poor, moderate, good, or excellent. Categorical variables were compared with the use of the Chi-squared test; an independent-samples t-test was conducted to compare continuous variables. Logistic regression was performed to determine the main factors associated with low procedure tolerance. A total of 1,418 office hysteroscopies were performed. The mean age of the patients was 53 ± 13.8 years; 50.8% of women were menopausal, 17.8% were nulliparous, and 68.7% had a previous vaginal delivery. A total of 42.6% of women were submitted to an operative hysteroscopy. Tolerance was categorized as terrible or poor in 14.9% of hysteroscopies and moderate, good, or excellent in 85.1%. A terrible or poor tolerance was more frequently reported in menopausal women (18.1% vs. 11.7% in premenopausal women, p = 0.001) and women with no previous vaginal delivery (18.8% vs. 12.9% in women with at least one vaginal birth, p = 0.007). Low tolerance led more often to scheduling a second hysteroscopic procedure under anesthesia (56.4% vs. 17.5% in reasonable-to-excellent tolerance, p < 0.0005). Office hysteroscopy was a well-tolerated procedure in our experience, but menopause and lack of previous vaginal delivery were associated with low tolerance. These patients are more likely to benefit from pain relief measures during office hysteroscopy.

7536 Can Body Mass Index be a Predictor of Pain during Office Hysteroscopy? Findings from a Single-Center Study

<h3>Study Objective</h3> Improved technology and miniaturization of the hysteroscopes has allowed for the implementation of office hysteroscopies. One of the most common factors resulting in failure to complete the procedure during office hysteroscopy is pain. Given a society with increasing rates of obesity, there is no available evidence as to whether there is an impact of obesity in a patient's pain tolerance, therefore we seek to determine the relationship between BMI and pain level during office hysteroscopy. <h3>Design</h3> Retrospective chart review of 115 office diagnostic hysteroscopies performed without anesthesia using vaginoscopy technique. <h3>Setting</h3> University-based clinic. <h3>Patients or Participants</h3> Patients older than 18 years old presenting for in-office hysteroscopy. <h3>Interventions</h3> In-office hysteroscopy without anesthesia performed using vaginoscopy technique with rigid 5 mm diagnostic hysteroscope with 30-degree optic lens. <h3>Measurements and Main Results</h3> VAS pain scale from 0-10 was used immediate after the procedure to quantify pain. <h3>Conclusion</h3> There is no association between BMI and pain during office hysteroscopy procedures, therefore BMI is not a predictor of pain. Further studies may consider using a larger sample. In a society with increasing rates of obesity, it is important to address potential barriers to care for our evolving population.

Intrauterine Anesthesia in See and Treat Hysteroscopy – A Double Blind, Placebo Controlled Randomized Trial

<h3>Study Objective</h3> The primary aim of the current study is to evaluate the effect of local instillation of lidocaine in relieving pain during office operative hysteroscopy without anesthesia. Secondary aims include the rate of failure in performing the procedure and patient satisfaction among patients in the study group vs. controls. <h3>Design</h3> A randomized double-blind placebo-controlled study. <h3>Setting</h3> A university-affiliated hospital; office hysteroscopy clinic. <h3>Patients or Participants</h3> A Total of 100 patients who underwent operative office hysteroscopies were randomized with 50 in the intervention group and 50 in the control group. <h3>Interventions</h3> Ten mL of lidocaine 2% added to 1000 mL of saline solution that was used as the distension medium for hysteroscopy in the study group vs 1000 mL of saline alone in the control group. <h3>Measurements and Main Results</h3> Eighty-eight patients completed the study and were included in the analysis. The main pathology treated was retained products of conception (55 cases). A significant difference was found in the increment of pain level following the procedure measured by visual analog scale during operative stage of see and treat hysteroscopy (p=.027) and at the completion of the procedure (p=.032) between two groups. Patients' satisfaction level was similar between the two groups (88.8% for the study group and 89.3% for the control group). Success rates were also similar between the two groups at approximately 93%. No side effects were recorded in either group. <h3>Conclusion</h3> The addition of local anesthetic to the distension medium operative office hysteroscopy produces significant reduction in pain during and following the procedure without side effects.

8886 Endometrial Wound Healing Duration after Hysteroscopic Treatment of Type 2 and 3 Myomas

<h3>Study Objective</h3> To assess the mean resolution time of the fovea after hysteroscopic treatment of type 2 and type 3 myoma. <h3>Design</h3> Prospective observational study. <h3>Setting</h3> University of Naples Federico II, Naples, Italy. <h3>Patients or Participants</h3> <b>W</b>omen aged 30-50 years, with at least one type 2 or type 3 myoma, history of infertility or uterine bleeding who underwent hysteroscopic myomectomy. <h3>Interventions</h3> <b>A</b>ll patients underwent hysteroscopic myomectomy, using a 15 Fr or 26 Fr resectoscope, either outpatient or in the operating room. All surgical procedures were performed by one expert hysteroscopist. Cold loop myomectomy applied to bipolar resectoscope was used for the removal of the intramural component of the myomas. All women underwent repeated follow-up office hysteroscopies every week after the surgical procedure for the first month and then every two weeks for the following months <h3>Measurements and Main Results</h3> Thirty-one patients with type 2 or 3 myoma with infertility (26/31) or uterine bleeding (15/31) were enrolled. The resectoscopic myomectomy was successful in all cases, without any significant complications. Overall, the mean diameter of resected myomas was 23 mm. The fovea was almost completely restored between three to six weeks after surgery in case of myomas < 2 cm and on average within 56 days for myomas of any size. The resolution was faster in women < 40 years old. No correlation was observed between the resolution time of the fovea and the different localization of the myomas <h3>Conclusion</h3> These preliminary data showed short time to resolution of the fovea in case of type 2 and 3 myomas hysteroscopically treated. The respect of the myometrium and the reduced thermal injury obtained thanks to the cold loop technique applied to bipolar resectoscope, may have influenced the resolution time of the fovea

Uterine cavity evaluation after uterine preservation surgeries for morbidly adherent placenta.

The morbidly adherent placenta (MAP) is usually associated with maternal morbidity and mortality. The objective of this study was to evaluate the uterine cavity after uterine preservation surgeries for MAP. The study group comprised women ≥ 28 weeks pregnant with confirmed MAP, with a desire for future fertility, and who agreed to uterine preservation surgery for MAP. The uterine preservation surgeries done for MAP include the following: uterine artery ligation, placental-myometrial en bloc excision, and/or internal iliac artery (IIA) ligation. Participants managed by uterine preservation surgeries for MAP were evaluated 3-6 months after the surgeries using office hysteroscopies to evaluate the uterine cavity after uterine preservation surgeries (primary outcome). The secondary outcome measures the pregnancy outcome after uterine preservation surgery. The hysteroscopic examination of the uterine cavity after uterine preservation surgery for MAP showed normal uterine cavity in 36 participants (90%), while it showed abnormal uterine cavity in 4 participants (10%). The abnormal hysteroscopic findings were a single abnormal hysteroscopic finding (endometrial polyp) in 2 participants (5%) and 2 abnormal hysteroscopic findings (incompletely healed scar with unilateral tubal ostial occlusion) in 2 participants (5%). The incidence of pregnancy after uterine preservation surgeries for MAP was 7.5% (3/40). The uterine preservation surgeries for MAP in this study had no effect on menstrual pattern, uterine cavity, or future fertility. The effect of uterine preservation surgeries for MAP on menstrual pattern, uterine cavity, and future fertility should be evaluated in future larger studies.

Doula support in office hysteroscopy: results from a pilot study

Background: This pilot study aimed to evaluate the feasibility of doula support in office hysteroscopy and the potential effectiveness of doula support during office hysteroscopy to reduce anxiety and pain. Methods: Twenty-eight women, median age 43.5 (range 21–73), with indications for office hysteroscopy received doula support (intervention) or routine care (control group) during the procedure. Feasibility was measured in terms of successful office hysteroscopies, duration, and adverse events. Outcome measures were Spielberg State-Trait Anxiety Inventory-S (STAI-S), and the Numeric Rate Scale (NRS) for pain intensity. Results: The results showed similar success rates, duration, and adverse events between the groups, with no differences in reported pain intensity. Both groups had high, comparable levels of anxiety before the procedure (Doula group mean STAI-S score = 45.4, control group = 45.8). After the procedure, the doula group showed slightly increased anxiety while the control group showed slightly decreased anxiety. There was a significant difference between groups favoring the control group when comparing STAI-S mean score post-procedure (48.6 in the Doula group versus 44.1 in the control group p = 0.033). However, when analyzing the mean change across groups (p = 0.205) that difference was not significant. Discussion: To conclude, this pilot study suggests that Doula support may be feasible but not superior to routine care support in office hysteroscopy. High anxiety levels may be more relevant than pain during the procedure. Further investigation of the state and trait anxiety in office hysteroscopy populations in different health care contexts is recommended.

Addition of Lidocaine to the Distension Medium in Hysteroscopy Decreases Pain during the Procedure–A Randomized Double-blind, Placebo-controlled Trial

To evaluate the effect of adding a local anesthetic to the distension medium in office diagnostic hysteroscopy using the vaginoscopic approach on pain during the procedure. Secondary aims included documenting side effects, patient satisfaction, and the time needed to complete the procedure. Randomized double-blind placebo-controlled study. University-affiliated hospital; office hysteroscopy clinic. Total of 100 patients who underwent office hysteroscopies divided in half with 50 in the intervention group and 50 in the control group. Ten mL of lidocaine 2% added to 1000 mL of saline solution that was used as the distension medium for hysteroscopy in the study group vs 1000 mL of saline alone in the control group. A significant difference was found in the increment of pain as measured by visual analog scale after the hysteroscopy between the 2 groups. Patients receiving lidocaine had an average rise of 1.9 in the visual analog scale score after the procedure compared with 2.9 in the control group (p = .033). There was also a nonsignificant trend for shorter duration of hysteroscopy in the intervention group compared with the control group (180.1 vs 222.1 seconds, p = .08). Patients' satisfaction was high in both groups (98% for the study group and 92% for the control group). Success rates were also similar between the 2 groups at approximately 95%. No side effects were recorded in either group. The addition of local anesthetic to the distension medium in office hysteroscopy produces significant reduction in pain during the procedure without adding time to the procedure and without side effects.

Hysteroscopy Findings in Women with Thin Endometrium Scheduled for In Vitro fertilization in Niger Delta Region, Nigeria.

The effect of endometrial thickness on in vitro fertilization (IVF) outcome is still a subject of debate. It is unclear why a thin endometrium reduces IVF success rates. Our objective was to analyze the hysteroscopic findings in women scheduled for IVF who had an endometrial thickness less than 7 mm. Relevant data of patients scheduled for IVF cycles and found to have an endometrial thickness (ET) of <7 mm on transvaginal ultrasound scan (TVS) between April 1, 2010 and March 31, 2017, at a private fertility and minimal access surgery unit in the Niger-Delta region of Nigeria, were retrieved and documented. A total of 41 patients had ET <7 mm during the study period. These patients accounted for 2.8% of the 1487 IVF cycles performed during the same period. All 41 patients had office hysteroscopies performed, constituting 4.1% of the 1,002 hysteroscopies performed during the study period. The age range of the patients was 23 - 50 years with a mean of 39.9 ± 6.9 years, and the duration of infertility ranged from 3 to 13 years with a mean of 7.2 ± 2.5 years. Most of the patients (32, 78.1%) had secondary infertility. Sixteen patients (39.0%) had intrauterine adhesions. A thin endometrium, though infrequent during IVF treatment cycles, might be associated with undiagnosed intrauterine adhesions.

Diagnostic office hysteroscopy with the Storz TrophyScope® versus Cooper surgical Endosee®.

Office hysteroscopy (OH) is becoming increasingly popular. Our objective was to determine the use patterns, reported pain scores, and success rates of OH with the 2.9 mm Storz TrophyScope® and handheld portable Cooper surgical Endosee® device in a clinic without previous office hysteroscopy experience. A prospective cohort study of a hysteroscopy quality improvement database was conducted in a tertiary care center gynecology clinic. Patients undergoing OH with either the Storz TrophyScope® or Cooper Surgical Endosee® device were included. Of the 171 office hysteroscopies, 77 utilized the TrophyScope®, with 8 (10%) being inadequate, while 94 utilized Endosee®, with 13 (14%) being inadequate (P=0.50). Of the 13 inadequate Endosee® hysteroscopies, 4 (31%) were due to visualization, 4 (31%) to patient intolerance, 3 (23%) to cervical stenosis, and 2 (15%) to a combination of these factors. Of the 8 inadequate TrophyScope® hysteroscopies, 7 (87%) were due to patient intolerance and 1 (13%) to cervical stenosis. Of the 150 adequate office procedures performed, 52 cases underwent subsequent procedures in the operating room (OR). Of these, 26 (84%) of 31 Endosee® cases and 18 (86%) of 21 TrophyScope® cases were in agreement with OR procedure findings. A subgroup analysis comparing mean pain levels did not significantly differ between the two hysteroscopes. There was no difference in accuracy with OR pathologic diagnoses, adequacy of procedure, and reported pain scores when comparing the TrophyScope® and Endosee® in this prospective cohort. Larger studies are needed to confirm the sensitivity, and specificity for these newer, disposable office hysteroscopic devices.

Failed diagnostic hysteroscopy: Analysis of 62 cases

ObjectiveThe aim of the presented study is to improve the office hysteroscopy success rate identifying some of the factors associated to an unsuccessful procedure. Moreover it would highlight the importance of an adequate patients follow up after office hysteroscopy failure enlightening the uterine pathologies missed at the first attempt. StudydesignThis is a retrospective observational study. The Authors reviewed the medical records related to 516 office hysteroscopies performed from January 2016 to November 2018, extrapolating the data from the failed hysteroscopies occurred during this period. After the procedure failure all patients were offered to repeat the hysteroscopy under regional anesthesia in order to identify and treat uterine pathologies. Those patients, who declined to repeat the procedure, received an appropriate follow up. Each failure case is correlated with patient clinical characteristics, indications to hysteroscopy, risk factors presence, hysteroscopy patient compliance, pathology result and patient follow up. ResultsThe presented study shows an office hysteroscopy failure rate of about 12 %. Severe pain due to cervical stenosis, previous uterine surgery, postmenopausal status and marked uterine ventrifixation/retroflexion, represent the main reason why the procedure was not completed in an office setting. The uterine cavity was subsequently examined in only 26 (42 %) out of 62 patients who reported hysteroscopy failure, mostly repeating the procedure under regional anesthesia (24 cases) or performing vaginal hysterectomy for associated benign gynaecological pathology (2 cases). Endometrial malign pathology (endometrioid carcinoma) was diagnosed in 2 cases of them (7.7 %). Moreover the endometrial cavity remained so far unexplored in 36 (58 %) out of 62 patients, due to the patient refuse to repeat the hysteroscopy under anesthesia. Discussion and conclusionResults of the present study suggest that office hysteroscopy should be sussessful at the first attempt due to the patients’ refuse, in majority of cases, to repeat the procedure after a failure. To not repeat the hysteroscopy may lead to lose or delay important diagnosis, such as that of endometrial cancer. In this context, to counsel all patients prior the procedure may singnificanly help to identify those who may benefit of pharmacological cervical softening, local anesthetic injection or small caliber hysteroscopes usage, increasing the procedure success rate.

1438 Experience with the Storz Trophyscope® Versus Cooper Surgical Endosee® for Office Diagnostic Hysteroscopy

Study Objective Determine use patterns and success rates for office diagnostic hysteroscopy with the 2.9 mm Storz TROPHYSCOPE® and handheld portable Cooper Surgical Endosee device in a clinic setting. Design Prospective cohort study of a hysteroscopy quality improvement database. Setting Gynecology clinic in a tertiary care center. Patients or Participants Patients undergoing office hysteroscopy with either the Storz Trophyscope or Cooper Surgical Endosee device. Interventions Diagnostic office hysteroscopy. Measurements and Main Results Of the 172 office hysteroscopies, 78 utilized the Trophyscope, with 8 (10%) being inadequate, while 94 utilized Endosee, with 13 (14%) being inadequate (p=.64). Of the 13 inadequate Endosee hysteroscopies, 3 (23%) were due to visualization, 5 (39%) due to patient intolerance, 3 (23%) due to cervical stenosis, and 2 (15%) due to both patient intolerance and stenosis. Of the 8 inadequate Trophyscope hysteroscopies, 7 (87%) were due to patient intolerance and 1 (13%) to cervical stenosis (p=0.14). Of the 151 adequate office procedures performed, 52 cases underwent subsequent procedures in the operating room (OR) with hysteroscopy or hysterectomy (Table 1). Of these, 27 (84%) of 32 Endosee cases and 15 (75%) of 20 Trophyscope cases were in agreement with findings from the OR procedure (p=0.48). Conclusion There is no difference in adequate visualization or pathologic diagnoses with the Endosee and TrophyScope devices in this prospective cohort. Larger, adequately powered studies are needed to confirm the sensitivity and specificity for these newer, disposable office hysteroscopic devices. Determine use patterns and success rates for office diagnostic hysteroscopy with the 2.9 mm Storz TROPHYSCOPE® and handheld portable Cooper Surgical Endosee device in a clinic setting. Prospective cohort study of a hysteroscopy quality improvement database. Gynecology clinic in a tertiary care center. Patients undergoing office hysteroscopy with either the Storz Trophyscope or Cooper Surgical Endosee device. Diagnostic office hysteroscopy. Of the 172 office hysteroscopies, 78 utilized the Trophyscope, with 8 (10%) being inadequate, while 94 utilized Endosee, with 13 (14%) being inadequate (p=.64). Of the 13 inadequate Endosee hysteroscopies, 3 (23%) were due to visualization, 5 (39%) due to patient intolerance, 3 (23%) due to cervical stenosis, and 2 (15%) due to both patient intolerance and stenosis. Of the 8 inadequate Trophyscope hysteroscopies, 7 (87%) were due to patient intolerance and 1 (13%) to cervical stenosis (p=0.14). Of the 151 adequate office procedures performed, 52 cases underwent subsequent procedures in the operating room (OR) with hysteroscopy or hysterectomy (Table 1). Of these, 27 (84%) of 32 Endosee cases and 15 (75%) of 20 Trophyscope cases were in agreement with findings from the OR procedure (p=0.48). There is no difference in adequate visualization or pathologic diagnoses with the Endosee and TrophyScope devices in this prospective cohort. Larger, adequately powered studies are needed to confirm the sensitivity and specificity for these newer, disposable office hysteroscopic devices.

Vaginoscopy “No Touch” Technique: A Feasible Alternative to Paracervical Block for in Office Hysteroscopy [34E

INTRODUCTION: Hysteroscopy allows direct visualization of the uterine cavity. Traditionally, in office hysteroscopy is performed using a speculum and tenaculum to hold the cervix. However, the emergence of smaller diameter hysteroscopes along with the vaginoscopy no touch technique without the need of speculum or tenaculum has contributed for the procedure to be done in the office setting without the use of analgesia. This study reviews our experience of in office hysteroscopy using the vaginoscopy "no touch" approach. METHODS: Retrospective chart review of 22 in office hysteroscopies performed without analgesia using the vaginoscopy “No touch” technique from June 1, 2017 to January 31, 2018. Patients received 200 mcg of oral Misoprostol 30 minutes before the procedure. Data gathered included age, body mass index, prior vaginal deliveries, and pain during the procedure. Success was measured as the ability to enter the endometrial cavity and perform the expected procedure. RESULTS: The median age 45 SD ±10.0 and BMI of 26.9 SD ±4.4. Hysteroscopic indications were: 2 (9.1%) postmenopausal bleeding, 5 (22.7%) retained IUD, 7 (31.8%) for suspected polyp, 8 (36.4%) for abnormal uterine bleeding. Of the 22 procedures, 18 were successful completed (80%). The median pain on VAS scale reported immediately after the procedure was 3.8 SD ±0.8 All four of the unsuccessful procedures were in postmenopausal females, two of which due to severe cervical stenosis. There were no complications. CONCLUSION: In office hysteroscopies using the vaginoscopy “no touch” technique is a feasible and safe procedure. We recommend adopting this innovative, painless technique.

Office diagnostic hysteroscopy by vaginoscopy

Introduction: Diagnostic hysteroscopy is considered the gold standard for the inspection of the uterine cavity. The history of hysteroscopy started in 1806 with Philipp Bozzini, but the modern technique was first described by Raoul Palmer, who performed several exams in 1957, in the outpatient setting. The authors’ department has a wide experience in the minimal invasive approach techniques, with about 10,000 office hysteroscopies performed over the past 20 years.

107 - Initial Experiences With the Storz TrophyScope® Versus CooperSurgical EndoSee® for Office Diagnostic Hysteroscopy

Study Objective Determine use patterns and success rates for office diagnostic hysteroscopy with the 2.9 mm Storz TROPHYSCOPE® and handheld portable Cooper Surgical Endosee device in a clinic setting. Design Prospective cohort study of a hysteroscopy quality improvement database. Setting Gynecology clinic in a tertiary care center. Patients or Participants Patients undergoing office hysteroscopy with either the Storz Trophyscope or Cooper Surgical Endosee device. Interventions Diagnostic office hysteroscopy. Measurements and Main Results Of the 172 office hysteroscopies, 78 utilized the Trophyscope, with 8 (10%) being inadequate, while 94 utilized Endosee, with 13 (14%) being inadequate (p=.64). Of the 13 inadequate Endosee hysteroscopies, 3 (23%) were due to visualization, 5 (39%) due to patient intolerance, 3 (23%) due to cervical stenosis, and 2 (15%) due to both patient intolerance and stenosis. Of the 8 inadequate Trophyscope hysteroscopies, 7 (87%) were due to patient intolerance and 1 (13%) to cervical stenosis (p=0.14). Of the 151 adequate office procedures performed, 52 cases underwent subsequent procedures in the operating room (OR) with hysteroscopy or hysterectomy (Table 1). Of these, 27 (84%) of 32 Endosee cases and 15 (75%) of 20 Trophyscope cases were in agreement with findings from the OR procedure (p=0.48). Conclusion There is no difference in adequate visualization or pathologic diagnoses with the Endosee and TrophyScope devices in this prospective cohort. Larger, adequately powered studies are needed to confirm the sensitivity and specificity for these newer, disposable office hysteroscopic devices.

Office operative hysteroscopy: a retrospective review

Introduction: The indications for hysteroscopy have expanded including, beside diagnosis, treatment procedures that ideally could and should be performed, in the majority of cases, in an outpatient setting. The objectives of this report were to present and analyse the data from one year office operative hysteroscopies performed in our Department. Methods: Retrospective review of the clinical files of the women submitted to office operative hysteroscopies, performed without anesthesia, last year in our Department. Data analysis included not only main indications, hysteroscopic findings and procedures, complications, pain scale, and histological study, but also patients’ clinical data, such as age, parity, type of delivery, and hormonal status. Results: From the 513 office hysteroscopies performed during last year in our department, 228 (44,4%) were operative. Main indications, responsible for 93.9% of the operative hysteroscopies, were suspicion of an endometrial polyp, in 37.1% of the cases, followed by endometrial thickening, in 34.5%, and sterilization with Essure, in 22.3%. When the indication to perform the hysteroscopy was the suspicion of an endometrial polyp, one or more polyps were found in 72 cases (83.7%), with the other cases being associated more frequently to a non-pathological endometrium but also to the presence of synechiae, myomas or endometrial focal hypertrophy. Considering the cases of endometrial thickening, the most frequent findings included polyps, non-pathological endometrium, endometrial hypertrophy, and irregular formations with increased vascularization. The most frequent procedures performed were byopsies, in 87 cases, polypectomies, in 81 cases, and Essure insertion for hysteroscopic sterilization in 48 cases. About the pain scale (from 0 to 10), the minimum and maximum referred by the patients were 0 and 10, with the average being 3.9. Regarding complications, there were two cases of vasovagal reactions and one case of severe bleeding; about technical difficulties, there were 4 cases of failed attempt to introduce the Essure, in 3 cases unilaterally and in 1 case bilaterally, due to ostia stenosis. In the majority of cases the histological analysis showed benign findings; there were report of 7 cases of adenocarcinoma, 1 case of a poorly differentiated carcinoma, 2 case of malignant mullerian tumor, and 3 cases of complex hyperplasia with atypia. Conclusions: The use of office operative hysteroscopy has been increasing due to the fact that this is a “time-efficient and cost-effective procedure” with a high success rate. Thereby, in our department, there has been an increasing in the procedures performed under these conditions, with no deterioration in success, failure or complication rates. One of the problems usually described by authors is the pain associated, however, in our case, we had scarce cases of women that referred severe pain, with the average pain scale being between minor and moderate.

Office hysteroscopy: A report of 2402 cases

Hysteroscopy is the gold standard for evaluation of uterine cavity. It can be performed either as office setting or as day care procedure under general anaesthesia. Objective of this study is to assess feasibility and acceptability of office hysteroscopy without anaesthesia. This retrospective observational study took place in the gynaecologic unit of a teaching hospital. Women who had had an office hysteroscopy from 2010 to 2013 were included. Two thousand four hundred and two office hysteroscopies were carried out. Indications were menorrhagia (32.2%), postoperative evaluation (20.8%), infertility (15.8%), postmenopausal bleeding (10.9%) and other indications (20.3%). Women's mean age was 39.4 [39.0-39.9] and significantly higher among women with a failure of the office hysteroscopy (47.3 vs. 38.6, P<0.01). The failure rate was 9.5%, significantly higher in women with postmenopausal bleeding and lower in women for a postoperative evaluation. Assessment of an abnormal uterine cavity was done in 56.0% of cases with 28.7% of myomas, 27.2% of polyps, 17.7% of synechiaes, 14.7% of endometrial hypertrophies, 9.0% of trophoblastic retentions and 7.7% of uterine malformation. The complication rate of office hysteroscopy was 0.05%. Mean pain score during the examination was 3.57 out of 10 [3.48-3.66] and 0.89 [0.83-0.95] five minutes later. Office hysteroscopy is safe and feasible with little pain. A failure rate of 9.5% is reported, mainly for older women with postmenopausal bleeding.

Challenging the cervix: strategies to overcome the anatomic impediments to hysteroscopy: analysis of 31,052 office hysteroscopies

To report our experience on 10,156 cases of cervical stenosis (CS) diagnosed at office hysteroscopy. Retrospective study. Ambulatory clinics of diagnostic and operative hysteroscopy of two university teaching hospitals (Naples and Bari). A total of 31,052 patients undergoing office hysteroscopy. All of the paper and electronic reports of the office hysteroscopies performed from January 1996 to September 2014 were reviewed. Hysteroscopies were classified as successful (i.e., when access to and visualization of the entire uterine cavity was possible during the same procedure), incomplete (i.e., when access to uterine cavity was possible, but the entire uterine cavity could not be examined), or failed (i.e., when access to uterine cavity was not possible). CS was classified on the basis of localization: stenosis of external cervical ostium (ECO; type I); stenosis of distal third of cervical channel and the internal cervical ostium (ICO; type II); stenosis of the ICO (type III), and combined stenosis of ECO and ICO (type IV). The success rate at overpassing CS (including both successful and incomplete hysteroscopies) was the primary outcome measure. Secondary outcome measures were frequency and localization of CS in fertile and postmenopausal women and the frequency of use of technical maneuvers and/or miniaturized mechanical or bipolar instruments to overcome them. All hysteroscopies were performed with the use of a 5- or 4-mm rigid continuous-flow office operative hysteroscope by operators with different levels of expertise. The hysteroscopy technique used was standardized between the two centers and among all of the surgeons throughout the years. An access to the uterine cavity with a complete evaluation of the whole endometrial surface was possible in 93.9% of cases (29,152 patients). The main reasons of the 1,320 (4.3%) incomplete and 580 (1.9%) failed hysteroscopies were pain and CS, respectively. CS was identified in 10,156 women (32.7% of all procedures) and was significantly more frequent in postmenopausal than in fertile women (70.1% vs. 29.9%), except for type I stenosis, which was more frequent in fertile than in postmenopausal women. Type IV CS (44.3%) was the most commonly detected. Overall, CS was managed successfully with minimal discomfort in 98.5% of cases with technical maneuvers and miniaturized mechanical and/or bipolar instruments. Adhesiolysis with the distal tip of the hysteroscope by rotating the scope on the endocamera was the significantly more used strategy to overpass all types of CS (39.8% of cases), generally used in combination with miniaturized operative instruments (79.2%). Bipolar electrodes were more used in cases of type I and type IV stenosis (39.7%) compared with the other types of CS. CS and pain represent the main reasons for failed hysteroscopy. Recent technical and technologic innovations, together with increased operator experience and optimal pain management, have made it possible to overcome even severe CS with the use of office hysterosocpy, thus significantly reducing the rate of failed procedures and the need for operating room and general anesthesia.

Cold loops applied to bipolar resectoscope: A safe "one-step" myomectomy for treatment of submucosal myomas with intramural development.

To assess the safety and efficacy of cold loop myomectomy applied to bipolar resectoscope to perform "one-step" myomectomy of submucosal myomas with intramural involvement. Seventy-two patients with at least one symptomatic G1 or G2 myoma (Wamsteker's classification) underwent cold loop myomectomy from January 2011 to January 2013. All surgical procedures were performed using a 26Fr resectoscope and bipolar energy source. At one month after the procedure, all patients underwent an office hysteroscopy check-up. A subgroup of seven infertile patients underwent an office hysteroscopy every two-weeks to evaluate recovery time of the myometrial fovea. Resectoscopic myomectomies were successfully performed in one surgical step in 70 out of 72 patients without any significant complications. Overall, the mean diameter of resected myomas was 32.2 ± 9 mm. Median operative time was 34.2 ± 24.1 min. Median fluid deficit was 761.22 ± 480.34 ml. The fovea was almost completely restored (>80%) six weeks after surgery in six of the seven infertile patients who underwent repeated follow-up office hysteroscopies every two weeks. Data from the present study show that the use of cold loops applied to bipolar resectoscope represent an effective, safe technique for "one-step" myomectomy of G1-G2 myomas, allowing rapid recovery of the myometrial fovea.