Office Hysteroscopy Research Articles

1892 Laparoscopic Removal of Large Submucous Myomas

Video Objective This video demonstrates the laparoscopic approach in the management of large submucous myomas and minimal damage on the endometrium. Setting The patient is a 45 year old, G2 P2 woman with the complaint of heavy menstrual bleeding. Ultrasonography revealed a 5 × 4 cm submucous myoma with 10-20 % of intramural extension. Interventions Following serosal incision with bipolar energy instrument and entering the endometrial cavity, submucous myoma is extracted, the endometrial defect is closed submucosally with 2-0 V - lock suture. Myometrial defect is closed in double layer closure. Integrity of the endometrial cavity and the sutured line are assessed by an office hysteroscopy at the end of the procedure. Conclusion Given the fact that the complication risks increase with size and intramyometrial extension of submucous myomas during hysteroscopic surgery; laparoscopic myomectomy may be a better treatment option especially for patients with submucous fibroids more than 4 cm in size and/or with an intrauterine extension of more than 50%. A concomitant control hysteroscopy thereafter is useful to identify if the endometrial cavity remains intact after the procedure.

Robotic Assisted Laparoscopic Repair of Isthmocele

Video Objective This video demonstrates the technique for a Robotic assisted laparoscopic repair of a large Isthmocele. Setting A 41-year-old G1P1 woman presented with secondary infertility and postmenstrual spotting. Her first spontaneous pregnancy ended by cesarean section delivery 5 years ago. She has a 3 years history of secondary infertility and failed Intracytoplasmic sperm injection (ICSI). Transvaginal ultrasound showed a wedge-shaped hypoechoic area in the myometrium at the level of the previous cesarean scar and Pelvic MRI confirmed the diagnosis of Isthmocele. Interventions Diagnostic hysteroscopy done prior to the Robotic assisted Laparoscopy for endometrial cavity assessment and localization of the cesarean scar defect showed an endometrium studded with black hemosiderin-like lesions, biopsy was taken. Then a Robotic assisted Laparoscopic surgery started with dissection of the vesicovaginal plane and resection of the isthmocele pouch. Complete excision of fibrotic tissues performed and a Hegar dilator was placed to maintain cervico-uterine patency. The defect was then repaired in 3 layers. For the first two layers 0-polyglactin (Vicryl®) was used for faster absorption of the suture material in contact with the endometrial cavity. The third layer was closed using 2-0 delayed absorbable barbed sutures (V-LocTM). An adhesion barrier was placed overlying the suture line. The operative time was 150 minutes and the patient had an uneventful postoperative recovery. Conclusion The pathology of the endometrial biopsy showed the unusual finding of endometrial glands filled with blood.The postoperative vaginal ultrasound confirmed a well re-approximated uterine wall, a myometrial thickness of 14 mm and a continuous and intact endometrial lining at 6 weeks postoperatively. At 3 months a flexible office hysteroscopy showed excellent repair, complete healing of the lower uterine defect and a normal endometrial cavity with resolution of the abnormal lesions.Post-operatively, the patient denied any post-menstrual spotting and conceived spontaneously 4 months after the repair. This video demonstrates the technique for a Robotic assisted laparoscopic repair of a large Isthmocele. A 41-year-old G1P1 woman presented with secondary infertility and postmenstrual spotting. Her first spontaneous pregnancy ended by cesarean section delivery 5 years ago. She has a 3 years history of secondary infertility and failed Intracytoplasmic sperm injection (ICSI). Transvaginal ultrasound showed a wedge-shaped hypoechoic area in the myometrium at the level of the previous cesarean scar and Pelvic MRI confirmed the diagnosis of Isthmocele. Diagnostic hysteroscopy done prior to the Robotic assisted Laparoscopy for endometrial cavity assessment and localization of the cesarean scar defect showed an endometrium studded with black hemosiderin-like lesions, biopsy was taken. Then a Robotic assisted Laparoscopic surgery started with dissection of the vesicovaginal plane and resection of the isthmocele pouch. Complete excision of fibrotic tissues performed and a Hegar dilator was placed to maintain cervico-uterine patency. The defect was then repaired in 3 layers. For the first two layers 0-polyglactin (Vicryl®) was used for faster absorption of the suture material in contact with the endometrial cavity. The third layer was closed using 2-0 delayed absorbable barbed sutures (V-LocTM). An adhesion barrier was placed overlying the suture line. The operative time was 150 minutes and the patient had an uneventful postoperative recovery. The pathology of the endometrial biopsy showed the unusual finding of endometrial glands filled with blood.The postoperative vaginal ultrasound confirmed a well re-approximated uterine wall, a myometrial thickness of 14 mm and a continuous and intact endometrial lining at 6 weeks postoperatively. At 3 months a flexible office hysteroscopy showed excellent repair, complete healing of the lower uterine defect and a normal endometrial cavity with resolution of the abnormal lesions.Post-operatively, the patient denied any post-menstrual spotting and conceived spontaneously 4 months after the repair.

Benign Endometrial Polyp Recurrence after Office Hysteroscopic Polypectomy According to Surgical Procedure

Study Objective To compare the recurrence of benign endometrial polyps after hysteroscopic polypectomy performed with bipolar electrode (BE) or a small diameter hysteroscopic tissue removal system (HTRs). Design Prospective randomized study approved by the Institutional Review Board. Setting University-Hospital. Patients or Participants From January to December 2017, 93 of 120 fertile women, with a single endometrial polyp (between 10 and 20 mm) accepted to participate in the study and were randomized into two groups according to the type of surgical procedure assigned them by “QuickCalcs” of “Graphpad Software”. Only women with removed polyps, classified as “benign” after pathological assessment, were considered. Interventions A 4mm hysteroscope (Karl Storz, Germany) with BE (Versapoint, Gynecare) was used for 51 women (BE Group). The 5mm HTRs (TruClear 5C System, Medtronic, Ireland) was used for 42 patients (TruClear Group). All hysteroscopic polypectomies were performed in an office setting with the vaginoscopic approach during the early proliferative phase. Patients were scheduled for a 12-month postoperative transvaginal ultrasound evaluation. Measurements and Main Results Polyps were completely removed in 48 out of 51 (94.12%) BE group and in 40 out of 42 HTR group (95.24%). The median time for polypectomy was significantly lower for HTR group (3.6 ± 1.7 minutes) compare to 8.7 ± 2.8 minutes for the BE Group, p Conclusion In this prospective randomized study, hysteroscopic endometrial polypectomy resulted significantly quicker with small HTRs compared to BE without differences in terms of complete removal and recurrence of polyps.

Concordance between the Hysteroscopic Diagnosis of Endometrial Hyperplasia and Histopathological Examination.

The goal of this paper is to assess the concordance between the clinical diagnosis of Endometrial Hyperplasia (EH), suspected by senior gynecologists throughout outpatient office hysteroscopy, and the results from histopathological examination, in order to evaluate hysteroscopic accuracy for EH. A prospective cohort study was done at a Tertiary University Hospital. From January to December 2018, we enrolled women with the following criteria: abnormal uterine bleeding in post-menopause and endometrial thickening in pre-or post-menopause. Patients underwent office hysteroscopy with a 5 mm continuous-flow hysteroscope, and endometrial biopsies were taken using miniaturized instruments. Senior operators had to foresee histopathological diagnosis using a questionnaire. Histopathological examination was conducted to confirm the diagnosis. This study was approved by the local ethical and registered in the ClinicalTrials.gov registry (ID no. NCT03917147). In 424 cases, 283 clinical diagnoses of EH were determined by senior surgeons. A histopathological diagnosis was then confirmed in 165 cases (58.3%; p = 0.0001). Furthermore, 14 endometrial carcinoma and atypical hyperplasia were found. The sensitivity, positive predictive value, and negative predictive values for EH were, respectively, 90.4, 58.4, and 86.6%. Subdivided by clinical indication, the sensitivity was higher in patients with post-menopause endometrial thickening. The diagnostic accuracy of office hysteroscopy in the diagnosis and prediction of endometrial hyperplasia was high. Senior operators could foresee EHs in more than half the cases.

Optimal Timing of Dinoprostone Administration Prior to Office Hysteroscopy

Optimal Timing of Dinoprostone Administration Prior to Office Hysteroscopy

Evaluation of office hysteroscopy simulation as part of an OB/GYN residency training curriculum

Evaluation of office hysteroscopy simulation as part of an OB/GYN residency training curriculum

Office Hysteroscopy and Pipelle Endometrial Biopsy versus Diltation and Curettage in Diagnosis of Endometrial pathology in women with perimenopausal bleeding.

Office Hysteroscopy and Pipelle Endometrial Biopsy versus Diltation and Curettage in Diagnosis of Endometrial pathology in women with perimenopausal bleeding.

Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions.

Introduction: Intra-uterine adhesion (IUA) is one of the main causes of secondary infertility. The aim of this study was to evaluate the prevalence of IUA developing in women undergoing hysteroscopic resection for submucous myomas, polyps, and intrauterine synechiae and test the efficacy of second look hysteroscopy for diagnosing and treating post-surgical adhesions.Materials and Methods: We retrospectively collected data from reproductive age women who had a second look office hysteroscopy following hysteroscopic resection for myoma, polyp, or IUA at Foch hospital (Suresnes, France) between 2009 and 2017.Results: Six hundred and twenty two reproductive-age women underwent hysteroscopic resection for myoma, polyp, and/or IUA. Among them, 155 women had a second look hysteroscopy. In this group, 29/155 (18.7%) had IUA formation: 17/83 (20.5%) women who underwent hysteroscopic myomectomy, 5/46 (10.9%) women who underwent hysteroscopic polypectomy, and 7/26 (26.9%) women who underwent hysteroscopic lysis of adhesions. These IUA have been lysed by the office hysteroscopy procedure in 16/29 (55.2%) patients: 11/17 (64.7%), 2/5 (40%), and 3/7 (42.9%) in women who underwent hysteroscopic myomectomy, polypectomy and lysis of adhesion, respectively.Conclusion: IUA is a common complication of hysteroscopic surgery. Second look office hysteroscopy is an easy and effective procedure for diagnosing and removing newly formed IUA. It should be recommended for all women undergoing hysteroscopic resection for myomas, polyps, or IUA.

Accuracy of transvaginal ultrasound, saline infusion sonohysterography, and office hysteroscopy in the diagnosis of endometrial polyps

Background: Endometrial polyps (EPs) derive from overgrowths of stromal or endometrial glands supported by a fibrovascular core. Currently, there is no clear recommendation on the first-line tool to be employed between sonohysterography (SIS) and office hysteroscopy (ISC) in the evaluation of patients with the suspect of EPs. Materials and Methods: The authors performed a retrospective study on consecutive patients referred at their Unit with a suspicion of EP at transvaginal sonography (TVS). A total number of 1,243 patients were subject to TVS and ISC, while 128 ones were subject to TVS, SIS, and ISC. Primary outcome was the evaluation of the diagnostic performance of SIS and ISC in the detection of EPs. Results: ISC allowed the identification of EPs in all the cases (n=128/128 patients), with a sensitivity of 100% and specificity of 98%. For SIS, the sensitivity was 97% (n=124/128 patients) and specificity was 90%. Conclusions: ISC showed better diagnostic accuracy in comparison to SIS. Due to high diagnostic accuracy and the possibility to “see and treat” EPs in a single step, ISC should be considered as the gold standard approach in women with a suspect of EPs.

Vaginal Dinoprostone Prior to Diagnostic Office Hysteroscopy in Primarily Infertile Patients

Vaginal Dinoprostone Prior to Diagnostic Office Hysteroscopy in Primarily Infertile Patients

Vaginal Dinoprostone Versus Vaginal Misoprostol Prior to Diagnostic Office Hysteroscopy in Postmenopausal Patients

Vaginal Dinoprostone Versus Vaginal Misoprostol Prior to Diagnostic Office Hysteroscopy in Postmenopausal Patients

Vaginal Dinoprostone in Reducing Pain Perception During Diagnostic Office Hysteroscopy in Postmenopausal Women: A Randomized, Double-Blind, Placebo-Controlled Trial

To evaluate the efficacy of vaginal dinoprostone in reducing pain perception during diagnostic office hysteroscopy (OH) in postmenopausal women. Randomized, double-blind controlled trial. Tertiary university hospital. Postmenopausal patients scheduled for OH. Eligible participants were randomized in a 1:1 ratio to the dinoprostone and placebo groups. The severity of pain was assessed with a visual analog scale (VAS) ranging from 0, no pain to 10, worst pain during OH and 30 minutes after OH. The difference in the intensity of pain using the VAS score during the procedure. One hundred women (50 in each arm) were included in the study. The mean VAS score during OH was significantly lower in the dinoprostone group compared with the placebo group (3.9 ± 0.8 vs 5.6 ± 0.7; p <.001). The passage of the hysteroscope through the cervical canal was easier in the dinoprostone group (62.4 ± 9.5 vs 42.8 ± 10.8; p <.001). The 2 groups were comparable in terms of the duration of the procedure (p = .91) and the rate of adverse effects. Vaginal dinoprostone is effective in relieving pain during diagnostic OH in postmenopausal women with few adverse effects.

Two-step hysteroscopy for management of morbidly adherent retained products of conception.

Retained products of conception (RPOC) may occur as the result of a morbidly adherent placenta. In these cases, the hysteroscopic removal of RPOC may be technically challenging, and may require more than one hysteroscopic procedure. We sought to compare the clinical, surgical, and postoperative characteristics of cases managed by either a one-step hysteroscopy procedure or a two-step hysteroscopy approach. A retrospective review of all RPOC cases managed by hysteroscopy from 1/2013 to 3/2018. We included cases of RPOC occurring following delivery and medical or surgical pregnancy terminations. The rates of postoperative intrauterine adhesions were assessed by office hysteroscopy. A two-step procedure was required in 11 (3.9%) of the 358 women who underwent hysteroscopy for removal of RPOC during the study period. Comparison between the two-step and the one-step procedure groups revealed that the women in the two-step group were significantly older and the mean RPOC size was significantly larger (35.5 ± 4.1years versus 30.7 ± 5.9years, respectively, p = 0.01, and 38.6 ± 9.8mm versus 22.3 ± 7.5mm, p < 0.001, respectively). While the rates of intraoperative complications were similar between groups, readmission for postoperative fever was more common in the two-step group (18.2% versus 2.0%, respectively, p = 0.03). Postoperative intrauterine adhesions were diagnosed in 20.0% and 5.2%, respectively (p = 0.05). The two-step hysteroscopic approach enabled the complete removal of larger RPOC masses without the use of uterine curettage. The women who underwent the two-step procedure, however, were at increased risk for postoperative fever and postoperative intrauterine adhesions.

Are There Any Predictors of Endometrial Premalignancy/Malignancy within Endometrial Polyps in Infertile Patients?

Background: In the literature, there is no detailed analysis on the prediction factors for premalignancy/malignancy within endometrial polyps (EPs) in infertile patients. In this study, we aimed to determine the frequency of endometrial premalignancy/malignancy within EPs in infertile patients undergoing office hysteroscopic polypectomy and identify the factors that can potentially predict an endometrial premalignancy/malignancy within EPs. Method: A total of 957 infertile patients undergoing office hysteroscopy were diagnosed with EPs between February 2011 and August 2018. Patients were divided into 2 groups according to the pathological examination of EPs as benign (Group 1; n = 939) and premalignant/malignant (Group 2; n = 18). The medical records of all patients included in the study were reviewed retrospectively. Results: In this cohort, prevalence of endometrial premalignancy/malignancy within EPs was 18/957 (1.88%). On univariate analysis, age, polyp size, diabetes, hypertension, and causes of infertility did not differ between the 2 groups. On multivariate analysis, diffuse polypoid appearance of the endometrial cavity on office hysteroscopy (hazard ratio [HR] 4.1; 95% CI 1.576–10.785), duration of infertility, (HR 4; 95% CI 1.279–12.562), and body mass index (HR 7.9; 95% CI 2.591–24.258) were found to be independent predictors of endometrial premalignancy/malignancy within polyps in infertile patients. Conclusion: When diffuse polypoid appearance of the endometrial cavity is detected in an infertile patient during office hysteroscopy, hysteroscopy-guided resection and endometrial curettage should be performed. The pathological specimen should be sent for histopathological evaluation to diagnose possible endometrial premalignancy/malignancy within polyps.

Thirteen steps for office hysteroscopy with minimal discomfort

Thirteen steps for office hysteroscopy with minimal discomfort

Office Hysteroscopy in Infertility Work-out: the Role of Endometrial Hyperplasia in Southern Italian Women

Office Hysteroscopy in Infertility Work-out: the Role of Endometrial Hyperplasia in Southern Italian Women

Long-Term Reproductive Outcomes after Hysteroscopic Treatment of Dysmorphic Uteri in Women with Reproductive Failure: An European Multicenter Study

To evaluate the long-term reproductive outcomes in patients with dysmorphic uterus treated by hysteroscopic metroplasty with miniaturized instruments. Retrospective multicenter cohort study. Tertiary care university hospitals. The study was conducted on 214 women with a dysmorphic uterus (T-shaped, infantilis, or other type of dysmorphic uterus according to the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy classification system) with history of primary unexplained infertility (group 1) or repeated (>2) early miscarriages (group 2). Dysmorphic uteri were diagnosed by office hysteroscopy and 3-dimensional transvaginal ultrasound (3D-TVS). All patients underwent in office hysteroscopic metroplasty using a continuous-flow hysteroscope with a 5 Fr operating channel introduced into the uterine cavity using the vaginoscopic approach. Longitudinal incisions were performed on the fibromuscular constriction rings in the isthmic area and in some cases on the other uterine walls with a 5 Fr bipolar electrode or scissors. At the end of the procedure, an antiadhesive gel was applied into the uterine cavity to minimize adhesion formation. Postsurgical assessment of the uterine cavity was carried out through office hysteroscopy and 3D-TVS. All patients were followed for at least 24 months. The metroplasty was completed in all cases, resulting in a significant increase of uterine cavity volume (100%) and optimization of uterine morphology in 211 of 214 women (98.6%). After 60 months, the overall clinical pregnancy rate was 72.9% (n = 156/214), and the live birth rate was 80.1% (n = 125/156). Specifically, 74 of 156 women (47.4%) conceived spontaneously (with a median time to pregnancy of 5.5 months), of whom 32.4% had previously failed 1 or more attempts at in vitro fertilization/intracytoplasmic sperm injection. Our long-term follow-up data demonstrate that the hysteroscopic correction of dysmorphic uteri may result in a high live birth rate in women suffering from unexplained infertility or repeated miscarriages.

Modern evaluation of abnormal uterine bleeding

Abnormal uterine bleeding in women older than age 40 years, and certainly in menopausal patients, mandates evaluation, mainly to exclude cancer and hyperplasia, but also to better diagnose the source of the bleeding to appropriately manage the patient. In the past, dilation and curettage was the mainstay of diagnosis. This gave way to in-office suction pump-generated biopsies. Most recently, disposable biopsy instruments with their own internal piston to generate suction have become the standard of care. Rarely has such a technique received such widespread acceptance with such limited validation. Transvaginal ultrasonography, when technically feasible, is a noninvasive way to image the endometrial cavity. Saline-infusion sonohysterography is a subset of transvaginal ultrasonography reserved for patients in whom an adequate endometrial echo is not seen or when an endometrial echo is seen but not sufficiently thin. Appropriate understanding and use of transvaginal ultrasonography and addition of sonohysterography when necessary can allow a clinical algorithm that can triage patients with abnormal uterine bleeding to (1) no anatomic pathology best treated expectantly; (2) a global endometrial process, in which case random blind endometrial sampling is appropriate; or (3) a focal endometrial abnormality in which case endometrial sampling should be done with the visualization offered by hysteroscopy. Newer disposable office hysteroscopes finally allow office hysteroscopy to be done as a truly “point-of-care option.” Finally, the incidence of thick endometrial echo found incidentally in postmenopausal women with no bleeding is extremely high (10–17%) and should not trigger automatic invasive endometrial evaluation.

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.

Music and Its Impact on Pain and Anxiety During Office Hysteroscopy: A Randomized Controlled Trial [31E

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