Operative Hysteroscope Research Articles

Outpatient Hysteroscopic Polypectomy in Postmenopausal Women: A Comparison between Mechanical and Electrosurgical Resection

Study Objective Comparison of operating outcomes of office hysteroscopic polypectomy accomplished by mechanical or bipolar electrosurgical instrumentation. Design Prospective study (Canadian Task Force classification II-1). Setting Public hospital. Patients A total of 101 consecutive postmenopausal patients showing, during office hysteroscopy, 1 or more endometrial polyps measuring more than .5 cm. Interventions Hysteroscopy was carried out with a 2.9-mm optic and a 3.9- × 5.9-mm sheathed operative hysteroscope, without local anesthesia or systemic analgesia. The diagnostic phase was immediately followed by polyp resection, alternatively allocating the patients to mechanical or electrosurgical polypectomy. Hysteroscopic scissors were used for mechanical polypectomy, whereas 5F coaxial bipolar twizzle electrodes were used for electrosurgical polypectomy. Measurements and Main Results Effectiveness of polypectomy, operation time, and evaluation of induced pelvic pain (scored on a 1–10 cm visual analog scale), were the end points of comparison between the 2 techniques. Nine patients were excluded because of severe pelvic pain arising in the diagnostic phase or the finding of an oversize polyp requiring an estimated time of more than 30 minutes to be removed in the office setting. Of the remaining 92 patients, 46 underwent mechanical and 46 electrosurgical polypectomy. Clinical variables (i.e., age, age at menopause, parity, polyp size, and number) were similar in the 2 study arms. Polypectomy was accomplished in 79 (85.8%) of 92 patients. Among the considered clinical variables, effectiveness of resection was significantly related to age of patients (p = .04) and polyp size (p = .004). Mechanical and electrosurgical polypectomy was completed in 37 (80.4%) of 46 patients and in 42 (91.3%) of 46 patients, respectively (p = .13). Furthermore, mechanical and electrosurgical resections did not significantly differ as regards median surgical time (15.0 min [range 5–45] and 15.5 min [range 8–40], respectively; p = .53) and visual analog scale scores (3.7 ± 2.5 and 3.2 ± 1.9, respectively; p = .48). No major complications were recorded. Atypical polyp histology occurred in 9 (8.8%) patients, 5 of whom were asymptomatic. Conclusion Outpatient see-and-treat polypectomy represents a safe and effective alternative to resectoscopic polypectomy, leading to a complete polyp excision in about 80% of postmenopausal patients. No differences in the rate of polyp excision, surgical time, or induced pelvic discomfort were observed between electrosurgical and mechanical techniques.

Cost-Effectiveness Analysis Comparing the Essure Tubal Sterilization Procedure and Laparoscopic Tubal Sterilization

ObjectiveTo analyze the financial implications of establishing a hysteroscopic sterilization program using the Essure micro-insert tubal sterilization system in an ambulatory clinic. MethodsA retrospective cohort study (Canadian Task Force classification Type II-2), in an ambulatory women’s health clinic in a tertiary hospital, of 108 women undergoing Essure coil insertion between 2005 and 2006, and 104 women undergoing laparoscopic tubal sterilization for permanent sterilization between 2001 and 2004. The Essure procedures used a 4mm single channel operative hysteroscope and conscious sedation (fentanyl and midazolam); the laparoscopic tubal sterilizations were completed under general anaesthesia with a 7mm laparoscope and either bipolar cautery or Filshie clips. Costs associated with the procedure, follow-up, and management of any complications (including nursing, hospital charges, equipment, and disposables) were tabulated. ResultsThe Essure coils were successfully placed on the first attempt in 103 of 108 women (95%). Three patients required a second attempt to complete placement and two patients required laparoscopic tubal sterilization after an unsuccessful Essure. All 104 laparoscopic tubals were completed on the first attempt with no complications reported. The total cost for the 108 Essure procedures, including follow-up evaluation, was $138 996 or $1287 per case. The total cost associated with the 104 laparoscopic tubal sterilization procedures was $148 227 or $1398 per case. The incremental cost-effectiveness ratio was $111. ConclusionsThe Essure procedure in an ambulatory setting resulted in a statistically significant cost saving of $111 per sterilization procedure. Carrying out the Essure procedure in an ambulatory setting frees space in the operating room for other types of cases, improving access to care for more patients.

Endometrial vaporization of the cervical stump employing an office hysteroscope and bipolar technology

We report the successful treatment of a 40-year-old woman with ongoing cyclical vaginal bleeding lasting 10 days after laparoscopic subtotal hysterectomy. Hysteroscopic vaporization of the endometrial stripe in the cervical stump was performed in an office setting, using a 5-mm Bettocchi double-channel operative hysteroscope armed with a bipolar electrode.

Successful treatment of iatrogenic complete cervical occlusion with an innovative use of a multipurpose drainage catheter

Successful treatment of iatrogenic complete cervical occlusion with an innovative use of a multipurpose drainage catheter

A new curriculum for hysteroscopy training as demonstrated by an objective structured assessment of technical skills (OSATS)

The purpose of this study was to develop an effective curriculum to teach hysteroscopy, as well as to develop an objective assessment instrument (OSATS). All 24 residents in our training program attended a 3-hour hysteroscopy curriculum in each of 3 years. Each year after the curriculum, an OSATS was administered consisting of an assembly and operative task. Each task was evaluated with a task-specific checklist and a previously validated global assessment form. Twenty-four residents from an outside institution served as controls. All residents were examined by blinded and unblinded examiners. The reliability coefficient was .7857 for the checklist and .9763 for the global scale. Interrater reliability for the checklist was .7478 and ranged from .4222 to .9329 for the global instruments. Evaluation of construct validity revealed that the junior residents at both locations did significantly worse on the checklist and global scale than the senior residents for all 3 years of the study (P < .001). Those residents provided the curriculum did significantly better on both the checklist and the global scale than the resident controls with a mean of 45% versus 63% for the checklist and 18.3 versus 24.9 for the global score. (P = .001 checklist, P = .007 global scale). This curriculum is an effective way to impart knowledge and skill in the assembly and use of the operative hysteroscope. The checklist developed for this OSATS has excellent reliability and construct validity.

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To determine the prevalence of atypical hyperplasia, and endometrial cancer in asymptomatic postmenopausal women with endometrial polyps on atrophic endometrium, removed by hysteroscopic polypectomy. Retrospective multicenter study. University and tertiary care hospitals. Asymptomatic postmenopausal women with standardized sonographic (endometrial thickness ≤ 4mm), and/or hysteroscopic (visual diagnosis) diagnosis of endometrial polyp on atrophic endometrium, were retrospectively reviewed from 2000 to 2004. Patients on HRT and/or TMX treatment were excluded. All women underwent transvaginal sonography (TVS) with color- and/or power-Doppler evaluation, sonohysterography in selected cases, and/or diagnostic hysteroscopy (HYS). Hysteroscopic polypectomy was performed by using office operative hysteroscope or by resectoscope. Demographic, sonographic and hysteroscopic data were recorded. Histology of the removed polyp was the main outcome. 637 consecutive patients were analyzed among those so far included. Mean age (±SD) was 62 years ±8. Mean years after menopause were 13±13. Mean BMI was 26±5. Mean diameter of endometrial polyp at TVS and/or HYS was 18±15mm. Typical, atypical hyperplasia, and cancer were 4.9%, 1.6%, and 0.2%, respectively. One polypoid cancer was found. This first ad interim analysis of a larger multicenter study observed one case of endometrial cancer in asymptomatic postmenopausal women with endometrial polyp on atrophic endometrium. This confirmed the reliability of endometrial thickness ≤ 4mm and hysteroscopic visual diagnosis for the exclusion of endometrial disease. This retrospective study adds evidence to the feasibility of a conservative management of asymptomatic polyps. Monitoring criteria need to be established.

OC7.03: Symptomatic postmenopausal women with endometrial polyps removed by hysteroscopy: prevalence of atypical hyperplasia, and cancer in a multicentre Italian study

Objective: To determine the prevalence of atypical hyperplasia, and endometrial cancer in asymptomatic postmenopausal women with endometrial polyps on atrophic endometrium, removed by hysteroscopic polypectomy. Methods: Asymptomatic postmenopausal women with standardized sonographic (endometrial thickness ≤4 mm), and/or hysteroscopic (visual diagnosis) diagnosis of endometrial polyp on atrophic endometrium, were retrospectively reviewed from 2000 to 2004. Patients on HRT and/or TMX treatment were excluded. All women underwent transvaginal sonography (TVS) with colorand/or powerDoppler evaluation, sonohysterography in selected cases, and/or diagnostic hysteroscopy (HYS). Hysteroscopic polypectomy was performed by using office operative hysteroscope or by resectoscope. Demographic, sonographic and hysteroscopic data were recorded. Histology of the removed polyp was the main outcome. Results: 637 consecutive patients were analysed among those so far included. Mean age (± sd) was 62 years ±8. Mean years after menopause were 13 ± 13. Mean BMI was 26 ± 5. Mean diameter of endometrial polyp at TVS and/or HYS was 18 ± 15 mm. Typical, atypical hyperplasia, and cancer were 4.9%, 1.6%, and 0.2%, respectively. One polypoid cancer was found. Conclusions: This first ad interim analysis of a larger multicentre study observed one case of endometrial cancer in asymptomatic postmenopausal women with endometrial polyp on atrophic endometrium. This confirmed the reliability of endometrial thickness ≤4 mm and hysteroscopic visual diagnosis for the exclusion of endometrial disease. This retrospective study adds evidence to the feasibility of a conservative management of asymptomatic polyps. Monitoring criteria need to be established.

Hysteroscopic permanent tubal sterilization using a nitinol-dacron intratubal device without anaesthesia in the outpatient setting: procedure feasibility and effectiveness

Hysteroscopic permanent tubal sterilization has recently been introduced, resulting in a non-invasive, safe and effective technique. The aim of this study was to assess the feasibility of outpatient hysteroscopic tubal sterilization using a nitinol-dacron intratubal device without anaesthesia and to assess patient procedure compliance. We untertook a prospective study of 36 consecutive cases of outpatient hysteroscopic tubal sterilization using a nitinol-dacron intratubal device without anaesthesia. Tubal sterilization was performed by placing the device with the aid of a 5.2-mm continuous-flow operative hysteroscope. At the end of the procedure women were asked to rate the pain experienced on a visual analogue scale (VAS) (0, no discomfort to 100, severe discomfort). Successful device placement was assessed after 3 months by hysterosalpingography and diagnostic hysteroscopy. Successful bilateral placement was obtained in 32 patients (88.9%); in one (2.8%) the placement was monolateral; and in three (8.3%) the procedure failed. Mean operating time was 8.6 +/- 5.3 min. A mean VAS of 36.1 +/- 23.9 was recorded. The nitinol-dacron intratubal device is safe, appears to be effective long-term, is non-invasive and can be used in the outpatient setting without anaesthesia. Low-level discomfort was experienced by the patients. Limitations of its use include that it is not effective immediately, it is irreversible, it requires special equipment and training, and it is difficult to use in cases of uterine anomalies. We conclude that this method may be offered to all woman asking for permanent tubal sterilization, particularly those who refuse or have contraindications for anaesthesia.

Outpatient Hysteroscopic Polypectomy in 237 Patients: Feasibility of a One-Stop “See-and-Treat” Procedure

Study Objective To evaluate the feasibility of a “see-and-treat” office polyp resection, using a 5-mm sheathed operative hysteroscope. Design Retrospective study (Canadian Task Force classification II-2). Setting Public hospital. Patients Two hundred thirty-seven patients suffering from endometrial polyps who underwent outpatient hysteroscopy. Interventions Office polypectomy with anesthetic paracervical block (120 patients) or without (117 patients) using either mechanical (104 patients) or bipolar coaxial electrosurgical (107 patients) instrumentation. In 26 patients, we stopped the procedure before surgery because of intervening adverse events or polyps judged unresectable with an office-based procedure. A 10-cm visual analog scale (VAS) was used to rate patients' pelvic pain perception. Measurements and Main Results Overall effective polyp resection rate was 81.2% (191 of 235 evaluable patients). An inverse, although not significant (r = -.44) correlation was found between accomplished polypectomies and polyp size, ranging from 96.0% to 18.7% when the diameter of polyps was below 1 cm and above 4 cm, respectively (50 of 52 and 3 of 16 successfully accomplished procedures, respectively). No significant differences were found between successful resection rates (83.3% and 80.2%, respectively; p = .10) and VAS scores (2.2 ± 2.6 and 3.6 ± 2.9, respectively; p = .30) obtained in 79 premenopausal and 156 postmenopausal patients. Paracervical block administration (118 evaluable patients) matched with no anesthetic support (117 patients) was not associated either with an improved rate of resection (85.5% and 76.9%, respectively; p = .10) or with pelvic pain perception (VAS scores 3.3 ± 2.9 and 3.0 ± 2.8, respectively; p = .94). Visual analog scale scores were significantly lower (2.8 ± 2.5 and 4.7 ± 3.6, respectively; p = .001) and polyp resection rates were significantly higher (84.3% and 67.4%, respectively; p = .01) in 192 parous versus 43 nulliparous patients. Polypectomy failed in 44 of 235 patients (18.7%); the leading causes of failure were intolerable pelvic pain in 18 patients (7.6%) and polyp size in 17 patients (7.2%). Other than pelvic pain, the only adverse event we observed was clinical vasovagal reaction in four patients (1.7%). Conclusion One-stop outpatient hysteroscopic polypectomy is effective in about 80% of patients. With proper preoperative selection, it can be offered as a reliable option to avoid general anesthesia and resectoscopic surgery.

Advantages of a new 4.0 mm operative office hysteroscope

Advantages of a new 4.0 mm operative office hysteroscope

Comparison of hysteroscopic and hysterectomy findings for assessing the diagnostic accuracy of office hysteroscopy

Objective: To assess the diagnostic accuracy of office hysteroscopy by comparing the hysteroscopic findings with the histologic findings on the hysterectomy specimens. Design: Retrospective clinical study. Setting: University-affiliated hospital. Patient(s): Review of the hospital records of 443 patients who underwent office hysteroscopy and, within 2 months, hysterectomy. Intervention(s): We compared the hysteroscopic findings (including targeted biopsies) with the histologic findings that were obtained after hysterectomy. The results of this study were then compared with those of a previous study in which we examined the diagnostic accuracy of dilatation and curettage (D&C). Main Outcome Measure(s): We evaluated the diagnostic accuracy of office hysteroscopy. Result(s): When compared with the histologic diagnosis of the uterus, the hysteroscopic findings showed a diagnostic sensitivity of 98%, a specificity of 95%, a positive predictive value (PPV) of 96%, and a negative predictive value (NPV) of 98%. Hysteroscopy was found to have a greater diagnostic accuracy than D&C: the sensitivity and the NPV of the two diagnostic procedures were statistically different. Conclusion(s): Office hysteroscopy is confirmed as a powerful diagnostic tool, but targeted biopsies, performed with a small diameter operative hysteroscope, must be performed in cases of suspect endometrium to confirm the image-based diagnosis.

Echosight Patton Coaxial Catheter-Guided Hysteroscopy

Two women requiring assisted reproduction had cervical stenosis on diagnostic evaluation. Office hysteroscopy was performed with paracervical block supplemented with mild intravenous sedation. When cervical pathology precluded placement of a diagnostic hysteroscopy, an Echosight Patton coaxial catheter with an outer echogenic sheath (5.7F) and inner 0.018-inch diameter guidewire with coude tip was introduced transcervically. Intraoperative transvaginal ultrasound was performed to ensure proper placement into the uterine cavity. When the uterine cavity was identified, cervical pathology was corrected with a VersaPoint electrosurgical electrode with bipolar coagulation through an operative hysteroscope. Concomitant diagnostic laparoscopy was not necessary. Echosight Patton coaxial catheter-guided ultrasound is a reassuring method to confirm hysteroscopic placement.

Hysteroscopic evaluation of the endometrium in postmenopausal women taking tamoxifen

To evaluate hysteroscopic endometrial changes due to tamoxifen therapy in postmenopausal women with breast cancer. Retrospective study (Canadian Task Force classification II-2). University-affiliated hospital. Patients. Eighty-eight postmenopausal women (or with iatrogenic amenorrhea) receiving tamoxifen 20 mg/day for at least 1 year for breast cancer. Record review of patients undergoing transvaginal sonography (TVS) and office hysteroscopy with eye-directed biopsy specimens obtained with a 5-mm, continuous-flow, operative hysteroscope. Patients with thickened endometrium and pathologic findings at hysteroscopy had taken tamoxifen for significantly longer times than those without such findings (p < 0.05). Our findings confirm the estrogenic effect of tamoxifen on endometrium. Endometrial evaluation by TVS suggests further diagnostic procedures, but only hysteroscopy allows the surgeon to visualize endometrial lesions and obtain eye-directed biopsy tissue.

Hysteroscopic evaluation of menopausal women with endometrial thickness of 4 mm or more

To assess the diagnostic and operative potential of hysteroscopy in postmenopausal patients selected by ultrasound criteria. Cohort study (Canadian Task Force classification II-2). Outpatient ultrasound and hysteroscopy department of a university-affiliated hospital. One hundred fifty-five postmenopausal women with endometrial thickness of 4 mm or more by ultrasound, in menopause for at least 1 year, with or without menopausal complaints. Transvaginal ultrasound and office hysteroscopy with eye-directed biopsy specimens using a 5-mm, continuous-flow, operative hysteroscope. Of the 155 women, 129 (83%) were asymptomatic (irregular bleeding). Hysteroscopy showed endometrial pathology in 28% of asymptomatic patients (23 polyps, 5 cases of hyperplasia, 8 submucous myomata) and 76% of symptomatic women (13 polyps, 6 hyperplasia, 1 submucous myoma). Hysteroscopic results compared with histologic diagnosis showed a positive predictive value equal to 97. 1% and 95% in asymptomatic and symptomatic women, respectively, and a negative predictive value equal to 100% in both groups. Office hysteroscopy with endometrial biopsy samples has a diagnostic and operative role in postmenopausal patients selected based on endometrial thickness on ultrasound, in view of the high prevalence of endometrial pathology in both symptomatic and asymptomatic women.

Hysteroscopic evaluation of menopausal patients with sonographically atrophic endometrium

To assess the diagnostic and operative potential of hysteroscopy in postmenopausal patients selected by ultrasound criteria. Prospective evaluation (Canadian Task Force classification II-2). Outpatient ultrasound and hysteroscopy department of a university-affiliated hospital. Two hundred twelve women with an endometrial thickness less than 4 mm on ultrasound and in menopause for at least 1 year. Transvaginal ultrasound and office hysteroscopy, with eye-directed biopsy specimens obtained with a 5-mm, continuous-flow operative hysteroscope, and performed without anesthesia. Only 13 (6%) patients were symptomatic (irregular bleeding). Hysteroscopic diagnosis of endometrial polyps in three women (23%) was confirmed by histology. In the remaining 199 (94%) asymptomatic patients with atrophic endometrium on ultrasound, hysteroscopy showed an endometrial pathology in 10% (16 polyps, 4 submucous myomas); in one patient histologic evaluation disclosed focal adenocarcinoma in an endometrial polyp. Hysteroscopy allows a proper histologic diagnosis, even in asymptomatic postmenopausal women with atrophic endometrium on ultrasound.

Hysteroscopic endometrial evaluation in postmenopausal women taking tamoxifen for breast cancer

27. Hysteroscopic Endometrial Evaluation in Postmenopausal Women Taking Tamoxifen for Breast Cancer O Ceci, S Bettocchi, F Marello, RD Venere, AR Pellegrino, A Masciandaro, R Zaccaro. II Institute of Obstetrics and Gynecology, University of Bari, Bari, Italy. Objective. To evaluate endometrial modifications in postmenopausal women with breast cancer taking tamoxifen. Measurements and Main Results. Eighty-eight postmenopausal women (age 37-81 yrs) underwent TVUS and office hysteroscopy with eye-directed biopsies using a 5-ram continuous-flow operative office hysteroscope. Eighteen patients had received tarnoxifen for less than 12 months (range 4-11 too, group 1) and 70 for at least 12 months (range 12-72 mo, group 2). Transvaginal ultrasound revealed endometrial thickness greater than 5 mm in 62 women in group 1 and 7 in group 2. In group 1, hysteroscopy revealed 2 endometrial polyps, and in group 2 it found 26 endometrial polyps, 9 cases of endometrial hyperplasia, and 4 areas of focal adenocarcinoma. Twelve women in group 2 complained of abnormal uterine bleeding, whereas all patients in group 1 were asymptomatic. Conclusion. These data confirm the estrogenic effect of tamoxifen on endometrium. Endometrial evaluation by TVUS can suggest further diagnostic procedures (i.e., sonohysterography) but only hysteroscopy allows visualization of lesions and eye-directed biopsies. 28. Office Treatment of Large Endometrial Polyps Using the VersaPoint Bipolar Device O Ceci, F Marello, RD Venere, AR Pellegrino, L Laricchia, S Bettocchi. II Institute of Obstetrics and Gynecology, University of Bari, Bari, Italy. Objective. To demonstrate the possibility to treat fibrotic polyps larger than 1.5 cm in an office setting using a normal 5 mm operative hysteroscope without anesthesia instead of the resectoscope. Measurements and Main Results. Thirty-five women (age 21-63 yrs) with a history of AUB or sterility underwent resection of polyps with a 5-mm operative hysteroscope and 5F bipolar probe (VersaPoint) without anesthesia or analgesia. Only two postmenopausal women were asymptomatic, and polyps were occasionally discovered during evaluation for HRT. Polyps were sliced into pieces large enough to be extracted through the internal cervical ostium with the help of a 5F grasping forceps. Particular attention was paid to vaporization of a polyp's base to avoid regrowth. In all patients polyps were larger than 1.5 cm. Patient discomfort was minimal: 29 women had none, 4 had mild discomfort comparable with menstrual pain, and the remaining 2 had light pain. Average operating time was 19 minutes. Follow-up at 3 months showed a normal uterine cavity in all patients, with no reappearance of pathology. Conclusion. Endometrial fibrotic polyps larger than 1.5 cm can be treated in an outpatient or office setting without significant discomfort and with minimal operating time. Resectoscopy should be considered only for specific, selected cases. 29. Is ThermaChoice an Office Procedure? 1j Chaddha, 2R McCorvey, 2B Love. 1Atlanta West Women's Center, Douglasville, Georgia; 2Women's Wellness Center, Montgomery, Alabama. Objective. To discuss whether ThermaChoice could become an office procedure. Measurements and Main Results. In most studies 30% to 90% of cases were done with local anesthesia and intravenous sedation. In fact, in one study 90% of patients had local anesthesia in the office setting. With general anesthesia, ThermaChoice procedures can be performed in less than 30 minutes, and with local anesthesia they can be done in less than 20 minutes. If these cases could be shifted to the office, 80% of the cost of the ThermaChoice procedure could be eliminated. Conclusion. If the cost associated with ThermaChoice could be reduced, it could easily become an office

Management of submucous uterine fibroid with buserelin, gemeprost and hysteroscopic resection

A 19-year-old virgin presented with severe menorrhagia and a haemoglobin level of 76 g/L as a problem of management. A 5 cm diameter submucous fibroid was identified at hysteroscopy and biopsied but was unable to be removed. The luteinising hormone releasing hormone agonist, buserelin, was used in an attempt to produce symptomatic relief. One week after commencing buserelin therapy, severe menorrhagia occurred and the patient was admitted to hospital with a haemoglobin concentration of 24 g/L. Buserelin treatment was continued and no further menstruation occurred over the following year. As the patient was now well, hysteroscopic submucous fibroid resection was contemplated. Due to cervical rigidity in this teenager, a 1 mg gemeprost pessary was inserted into the posterior vaginal fornix three hours before surgery. This allowed an operative hysteroscope to be inserted into the uterus and a fibroid resection to be performed. Menstrual blood loss has been normal for six months after hysteroscopy. A combined medical and surgical approach may avoid hysterectomy in such problem patients.

Laminaria tent for diagnostic and operative hysterectomy.

Laminaria tents were inserted in 300 nonpregnant women to induce cervical dilation before diagnostic or operative hysteroscopy. All laminaria tents were inserted without anesthesia following uterine sounding. Diagnostic hysteroscopic procedures were performed with a 5.0 mm hysteroscope with video monitoring within 2-3 hours after insertion of the laminaria tent. Minimal analgesia was used. Operative procedures were performed approximately 24 hours after insertion of the laminaria tent with a 9 mm operative resectoscope. There were no complications with the use of the laminaria tent, such as infections or bleeding, but a few patients complained of mild menstrual-like lower abdominal discomfort. In all cases, the laminaria tent resulted in a softening and dilation of the cervix, which facilitated the passage of the diagnostic and operative hysteroscope.