Treatment Of Intrauterine Pathology Research Articles

Hysteroscopic Endometrial Ablation: From Indications to Instrumentation and Techniques-A Call to Action.

The development of minimally invasive techniques has led to the creation of innovative alternatives in cases where traditional methods are not applicable. In modern gynecology, hysteroscopy has become the gold standard for the evaluation and treatment of intrauterine pathology. Endometrial ablation (EA) is a procedure that uses different types of energy to destroy the endometrium and is currently used as an alternative technique in cases of heavy menstrual bleeding when medical treatment has failed and uterine preservation is desired. The aim of this review was to evaluate the feasibility, safety, and clinical outcomes of hysteroscopic EA as an alternative in patients with abnormal uterine bleeding. A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 1994 to June 2022, to evaluate the outcomes in patients with abnormal uterine bleeding (AUB) undergoing EA using hysteroscopic and non-hysteroscopic techniques. Only scientific publications in English were included. Twelve articles on the current use of endometrial ablation were included. Data on patient symptoms, tools used for EA, primary outcomes, and adverse events were recorded. EA should be considered an effective and safe approach in the management of patients with abnormal uterine bleeding caused by benign pathology, in whom medical treatment has failed or is contraindicated. Due to the lack of evidence, it would be interesting to determine whether EA would also have a role in the treatment of women with premalignant lesions, avoiding invasive surgical procedures or medical treatment in those patients for whom hysterectomy or the use of hormonal treatment is contraindicated.

Лечение внутриматочной патологии с использованием технологий fast track хирургии

Study Objective: Evaluation of the clinical effectiveness of the use of fast track surgery technologies in the treatment of submucosal uterine fibroids and endometrial polyps Study Design: Retrospective comparative study. Materials and methods. A retrospective comparative analysis of the data of 46 women was performed to assess the clinical effectiveness of the use of fast track surgery approach to treat intrauterine pathology. The 1st group included 23 women treated with the use of fast track surgery method. The 2nd group consisted of 23 women who underwent surgery with bipolar resectoscope in the gynecological hospital setting without the use of fast track surgery approach. Study Results. The complex application of fast track surgery technology components made it possible to achieve 100% efficiency in the treatment of intrauterine pathology, decrease pain-syndrome intensity in the postoperative period in 69.57% of women, ensure early mobilization of the patients and reduce hospital stay from 2–8 inpatient days to 2–2.5 hours. Conclusion. Implementing the fast track surgery principles into the treatment of patients with intrauterine pathology makes it possible to reduce a patient’s hospital stay, allows minimizing the consequences of the surgical injury and facilitates fast recovery of a woman. Keywords: intrauterine pathology, fast track surgery, diode laser, resectoscopy.

A Low-fidelity Model for Office-based Hysteroscopy with a Vaginoscopic Approach

Hysteroscopy is an established method for the diagnosis and treatment of intrauterine pathology. A vaginoscopic approach for office-based hysteroscopy confers less pain; however, trainees report lack of confidence with this procedure. We sought to create a low-fidelity simulation model for office-based hysteroscopy with a vaginoscopic approach and to evaluate the validity and reliability of this model. Prospective cohort study. A single academic medical center. Eligible participants included obstetrics and gynecology residents and attendings who regularly perform hysteroscopy. The vaginoscopy model was created with an inanimate female pelvis simulator with an exam glove placed within the vagina. Following 2 instructional videos, participants performed a hysteroscopy simulation with a vaginoscopic approach. The primary outcome was total score on a modified Global Rating Scale and Objective Structured Assessment of Technical Skills. The Objective Structured Assessment of Technical Skills outlines a series of steps that must be performed and was created with assistance from experts in hysteroscopy for providing content-oriented evidence of validity. Time to complete each task and total time were tracked. Participants completed a postprocedure survey assessing the model and experience. A total of 30 physicians participated, with 20 residents (9 junior and 11 senior) and 10 attendings. Attending physicians completed the simulation faster than junior residents (197.2 ± 30.9 vs 289.8 ± 107.4 seconds, p=.022). On the Global Rating Scale, both attending physicians and senior residents scored significantly higher than junior residents (26.1 ± 2.4 vs 22.5 ± 3.7, p=.01). Postsurvey data demonstrated that 93.3% of all participants were satisfied with simulation, 96.6% found it useful, 80% found it realistic, and 93% indicated that they may use this technique in the future. This study shows our low-fidelity model to be effective and useful and to improve confidence for vaginoscopic approach to hysteroscopy. Further studies are needed to assess ability to predict or improve clinical and surgical skills.

Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology.

Hysteroscopy provides a minimally invasive strategy to evaluate intrauterine pathology and manage conditions such as abnormal uterine bleeding, infertility, intrauterine adhesions, müllerian anomalies, and intrauterine foreign bodies. Increasing access to hysteroscopy procedures in the office has the potential to improve patient care by minimizing financial and logistical barriers, aiding in streamlined diagnosis and treatment planning, and potentially averting unnecessary operative procedures and anesthesia. Office hysteroscopy refers to procedures performed in outpatient settings where pain management involves no medications, oral nonsedating medications, local anesthetic agents, or oral or inhaled conscious sedation. We present best practices for the implementation of hysteroscopy in an office setting. These include appropriate patient selection, optimal procedural timing, cervical preparation for patients at highest risk of cervical stenosis or pain with dilation, individualized pain-management strategies, use of distension media, and video monitoring to engage patients in the procedure. We describe miniaturized equipment for use in the office setting and "no-touch" vaginoscopic approaches to limit patient discomfort. With appropriate training and experience, office hysteroscopy presents a simple and cost-effective modality for optimizing gynecologic care for our patients.

An In-Office Hysteroscopy VR/Haptic Simulation Platform for Training in Spatial Navigation and Passage of the Cervical Canal

Hysteroscopy is a type of gynecological procedure that enables diagnosis and treatment of intrauterine pathologies using a minimally-invasive approach. Recent advancements, especially in optics, made it possible to perform this procedure in an ambulatory, outpatient setting without anaesthesia. Yet, such approach introduces additional challenges to gynecologists, as the surgical instruments have to pass through the cervix, a narrow curved canal. This process can be traumatic and even cause tissue damage or rupture. Current training curricula mainly focus on general minimally-invasive surgical skills or on inpatient hysteroscopy. This paper describes the first virtual reality training system designed purposely for in-office hysteroscopy training featuring both passive and active haptic feedback. Design requirements were defined through a literature review and a survey of clinical experts. A dedicated platform was developed and tested with clinicians and medical students. The results of the conducted experiments verified the skill acquisition capabilities of the platform showing a.o. shorter execution time and path length, lower integral forces in most of non-expert participants. The results also demonstrated the capability of the system to differentiate between experts and non-expert groups. Reported findings suggest that the platform has the potential to evolve into an effective solution for in-office hysteroscopy training.

Experience in the use of hysteroscopy on an outpatient basis for the diagnosis and treatment of intrauterine pathology in patients with uterine factor infertility

Experience in the use of hysteroscopy on an outpatient basis for the diagnosis and treatment of intrauterine pathology in patients with uterine factor infertility

Validation of a Low-Fidelity Model for Office-Based Hysteroscopy with a Vaginoscopic Approach

<h3>Study Objective</h3> Hysteroscopy is an established method for the diagnosis and treatment of intrauterine pathology. A vaginoscopic approach for office-based hysteroscopy confers less pain; however, trainees report lack of confidence with this procedure. We sought to create a low-fidelity simulation model for office-based hysteroscopy with a vaginoscopic approach and to evaluate the validity and reliability of this model. <h3>Design</h3> Prospective cohort study. <h3>Setting</h3> A single site academic medical center. <h3>Patients or Participants</h3> Eligible participants included obstetrics and gynecology residents and attendings who regularly perform hysteroscopy. <h3>Interventions</h3> The vaginoscopy model was created with a female pelvis simulator and an exam glove placed within the vagina. Following two instructional videos, participants performed a hysteroscopy simulation with a vaginoscopic approach. The primary outcome was total score on a modified Global Rating Scale (GRS) and Objective Structured Assessment of Technical Skills (OSATS). The OSATS describes key procedural steps and was created with experts in hysteroscopy for content validity. Time to complete each task was recorded and summed. A post-procedure survey assessed the model and physician experience. <h3>Measurements and Main Results</h3> Ten attending and 20 resident physicians (9 junior and 11 senior) participated. Attending physicians completed the simulation significantly faster than junior residents (197(±31) vs. 290(±107) seconds, Cohen's <i>d</i>=1.2, p=0.022). On the GRS, both attending physicians (26.1(±2.4), <i>d</i>=2.5, p=0.001) and senior residents (22.5(±3.7), <i>d</i>=1.3, p=0.010) scored significantly higher than junior residents (17.4(±4.3)). Ninety-three percent of surveyed participants were satisfied with simulation, 97% found it useful, 80% found it realistic and 93% indicated that they may use this technique in the future. <h3>Conclusion</h3> This study shows our low-fidelity model to have construct, content, and face validity for vaginoscopic approach to hysteroscopy. A sufficiently powered, yet small sample of physician performance data yielded a large effect size in global mean score differences between attendings and junior residents. Physicians reported the technique to be satisfactory, realistic, and useful for future application.

Peculiarities of treatment and prevention of recurrences in women with intrauterine pathologies

The study is devoted to the problem of surgical treatment, rehabilitation program and prevention of recurrences in intrauterine pathologies (polyposis and uterine adhesion) in women with reduced reproductive potential. The urgency of this problem is characterized by a high frequency of abnormal uterine bleeding, hypomenstrual syndrome and amenorrhea, infertility and miscarriage. Clinical data include the own experience of treatment and rehabilitation of 66 patients; women with intrauterine synechiae (32 people) were included in group 1; 34 patients with hyperplastic form of chronic endometritis and polyposis were included in group 2. The control group included 30 healthy patients without gynecological pathology and menstrual irregularities. All women underwent therapeutic hysteroscopy with adgeolysis and polypectomy. In the postoperative period, 24 patients of the main group received the proposed program to restore the endometrium and its implantation potential. The comparison group included 42 patients with general principles of postoperative management. The key points of the proposed program were: immunomodulatory therapy, hormone replacement therapy and the use of autoplasma. As a result of the study, a reduction in the recurrence of the adhesive process was proved, as well as a significantly higher number of cases of pregnancy. Thus, for the comprehensive treatment of intrauterine pathology in young women with reduced reproductive potential it is important not only to use minimally invasive office hysteroscopy, an active postoperative rehabilitation period is of great importance too.

The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion Summary, Number 800.

This Committee Opinion provides guidance on the current uses of hysteroscopy in the office and the operating room for the diagnosis and treatment of intrauterine pathology and the potential associated complications. General considerations for the use of diagnostic and operative hysteroscopy include managing distending media, timing for optimal visualization, and cervical preparations. In premenopausal women with regular menstrual cycles, the optimal timing for diagnostic hysteroscopy is during the follicular phase of the menstrual cycle after menstruation. Pregnancy should be reasonably excluded before performing hysteroscopy. There is insufficient evidence to recommend routine cervical ripening before diagnostic or operative hysteroscopy, but it may be considered for those patients at higher risk of cervical stenosis or increased pain with the surgical procedure. In randomized trials, patients reported a preference for office-based hysteroscopy, and office-based procedures are associated with higher patient satisfaction and faster recovery when compared with hospital-based operative hysteroscopy. Other potential benefits of office hysteroscopy include patient and physician convenience, avoidance of general anesthesia, less patient anxiety related to familiarity with the office setting, cost effectiveness, and more efficient use of the operating room for more complex hysteroscopic cases. Appropriate patient selection for office-based hysteroscopic procedures for women with known uterine pathology relies on thorough knowledge and understanding of the target pathology, size of the lesion, depth of penetration of the lesion, patient willingness to undergo an office-based procedure, physician skills and expertise, assessment of patient comorbidities, and availability of proper equipment and patient support. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL) agree that vaginoscopy may be considered when performing office hysteroscopy because studies have shown that it can significantly reduce procedural pain with similar efficacy. The office hysteroscopy analgesia regimens commonly described in the literature include a single agent or a combination of multiple agents, including a topical anesthetic, a nonsteroidal antiinflammatory drug, acetaminophen, a benzodiazepine, an opiate, and an intracervical or paracervical block, or both. Based on the currently available evidence, there is no clinically significant difference in safety or effectiveness of these regimens for pain management when compared to each other or placebo. Patient safety and comfort must be prioritized when performing office hysteroscopic procedures. Patients have the right to expect the same level of patient safety as is present in the hospital or ambulatory surgery setting.

The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion, Number 800.

This Committee Opinion provides guidance on the current uses of hysteroscopy in the office and the operating room for the diagnosis and treatment of intrauterine pathology and the potential associated complications. General considerations for the use of diagnostic and operative hysteroscopy include managing distending media, timing for optimal visualization, and cervical preparations. In premenopausal women with regular menstrual cycles, the optimal timing for diagnostic hysteroscopy is during the follicular phase of the menstrual cycle after menstruation. Pregnancy should be reasonably excluded before performing hysteroscopy. There is insufficient evidence to recommend routine cervical ripening before diagnostic or operative hysteroscopy, but it may be considered for those patients at higher risk of cervical stenosis or increased pain with the surgical procedure. In randomized trials, patients reported a preference for office-based hysteroscopy, and office-based procedures are associated with higher patient satisfaction and faster recovery when compared with hospital-based operative hysteroscopy. Other potential benefits of office hysteroscopy include patient and physician convenience, avoidance of general anesthesia, less patient anxiety related to familiarity with the office setting, cost effectiveness, and more efficient use of the operating room for more complex hysteroscopic cases. Appropriate patient selection for office-based hysteroscopic procedures for women with known uterine pathology relies on thorough knowledge and understanding of the target pathology, size of the lesion, depth of penetration of the lesion, patient willingness to undergo an office-based procedure, physician skills and expertise, assessment of patient comorbidities, and availability of proper equipment and patient support. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL) agree that vaginoscopy may be considered when performing office hysteroscopy because studies have shown that it can significantly reduce procedural pain with similar efficacy. The office hysteroscopy analgesia regimens commonly described in the literature include a single agent or a combination of multiple agents, including a topical anesthetic, a nonsteroidal antiinflammatory drug, acetaminophen, a benzodiazepine, an opiate, and an intracervical or paracervical block, or both. Based on the currently available evidence, there is no clinically significant difference in safety or effectiveness of these regimens for pain management when compared to each other or placebo. Patient safety and comfort must be prioritized when performing office hysteroscopic procedures. Patients have the right to expect the same level of patient safety as is present in the hospital or ambulatory surgery setting.

Updates in office hysteroscopy: a practical decalogue to perform a correct procedure

Nowadays, hysteroscopy is the gold standard for the diagnosis and treatment of intrauterine pathologies as it represents a safe and minimally invasive procedure that allows the visualization of the entire uterine cavity. Numerous technological innovations have occurred over the past few years, contributing to the development and widespread use of this technique. In particular, the new small-diameter hysteroscopes are equipped with an operating channel in which different mechanical instruments can be inserted, and they allow not only to examine the cervical canal and uterine cavity but also to perform biopsies or treat benign diseases in a relatively short time without anesthesia and in an outpatient setting. In this scenario, the operator must be able to perform hysteroscopy in the correct way to make this procedure increasingly safe and painless for the patient. This review aims to describe the ten steps to perform a correct office hysteroscopy, starting from patient counseling to the therapy after the procedure.

Recurrence and prediction of abnormal uterine bleeding and re-intervention after initial hysteroscopic treatment: a retrospective cohort study.

To estimate the incidence of recurrence of complaints and repeated interventions after hysteroscopic treatment for abnormal uterine bleeding in premenopausal women and to determine potential predictors for re-intervention. This is a retrospective cohort study in two secondary care centers in the Netherlands. We included 313 premenopausal women who underwent hysteroscopy for complaints of abnormal uterine bleeding and who had intrauterine pathology visualized at ultrasound. The intrauterine structure was hysteroscopically removed. These women were compared with women who had a hysteroscopy for abnormal uterine bleeding, but in whom hysteroscopy showed no abnormalities. We used Chi-squared test for categorical variables and independent-samples T test for continuous variables. p Values less than 0.05 were considered to indicate statistical significance. In total, 262 women had intrauterine pathology removed at hysteroscopy; 136 (52%) women had recurrence of complaints, while 101 women (39%) underwent re-intervention. Heavy menstrual bleeding at baseline and multiparity were predictive factors for recurrence of abnormal uterine bleeding and re-intervention. In the 51 women with abnormal uterine bleeding in whom hysteroscopy showed no intrauterine abnormality, 29 women (60%) had recurrence of complaints and 12 (24%) a re-intervention. In premenopausal women with abnormal uterine bleeding, treatment of intrauterine pathology often does not reduce the complaints, thus questioning the effectiveness of hysteroscopic removal of these structures.

Effectiveness of Levonorgestrel - Releasing Intrauterine System in Perimenopausal Bleeding

The study aimed to compare the effectiveness of conservative methods [Levonorgestrel (C21H28O2) � releasing intrauterine system (52 mg), endometrial ablation, hysteroscopy] vs. hysterectomy in perimenopausal bleeding. The study population was represented by 270 women addressed to Genesiun Clinic between 2010-2018 for perimenopausal bleeding because of different pathological circumstances: endometrial hypertrophy, polyps, uterine fibroids, endocervical lesions, chronic endometritis, intrauterine device (IUD)-related pathology, congenital abnormalities. The hysteroscopy is considered the method of choice in the diagnosis/therapeutic management of hemorrhagic metropathy. The hysteroscopic surgery was superior to hysterectomy, taking into account the postoperative complications and recovery, resumption of sexual activity and working. Levonorgestrel-releasing IUS 52 mg proved safe and efficient in treating metrorrhagia associated with endometrial dysplasia, uterine fibroids, and polyps. The bipolar electrosurgical VERSAPOINT system demonstrated good results in the treatment of intrauterine pathology. Our results pointed out the alternative of a surgery a few months after the hysteroscopy and endometrial ablation, and also the possibility of repeating the hysteroscopy procedure after a while, in some cases.

Миниинвазивные вмешательства в диагностике и лечении внутриматочной патологии у женщин с бесплодием

Миниинвазивные вмешательства в диагностике и лечении внутриматочной патологии у женщин с бесплодием

358 - Fostering Fertility: Hysteroscopic Evaluation and Treatment of Intrauterine Pathology

358 - Fostering Fertility: Hysteroscopic Evaluation and Treatment of Intrauterine Pathology

Hysteroscopy before the first in vitro fertilization: a 7-year experience from a single center

Objective. This study aims to evaluate the importance of performing hysteroscopy prior to the first attempt of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) by specifying the incidence of intrauterine pathologies and the success of IVF/ICSI cycle. Methods. This is a retrospective review of 357 women who underwent their first cycle of IVF/ICSI treatment during a 7- year period. All women had primary infertility due to various factors: Polycystic ovary syndrome (n=101), male factor (n=84), tubal factor (n=78) and unexplained infertility (n=94). Results. The majority of the patients had normal hysteroscopic findings whereas 29.4% of them had an intrauterine pathology. Abnormal hysteroscopic findings included endometrial polyps (13.7%), submucous myomas (5.9%), uterine septa (4.5%), endometrial adhesions (3.1%), endometritis (1.4%) and cervical stenosis (0.8%). When compared to the women with normal hysteroscopy (n=252), the women with corrected hysteroscopic abnormalities (n=105) had significantly higher fertilization rate ( p =0.045), implantation rate ( p =0.038), clinical pregnancy rate ( p =0.022) and live birth rate ( p =0.022). When compared to the women with normal transvaginal ultrasonography and hysteroscopy findings (n=252), the women with normal ultrasonography and abnormal hysteroscopy (n=35) had significantly higher implantation rate ( p =0.044), clinical pregnancy rate ( p =0.032) and live birth rate ( p =0.030). Conclusion: The utilization of hysteroscopy before the first IVF cycle would allow the detection and treatment of intrauterine pathologies and structural uterine abnormalities that might be responsible for the failure of IVF and, thus, result in improved pregnancy rates.

Fertility after Myomectomy With the MyoSure® Hysteroscopic Tissue Removal System

To evaluate the fertility results and pregnancy outcomes in infertile women after treatment of intrauterine pathology with the MyoSure tissue removal system.

Histeroscopia oficinal: Estado del arte y revisión de la literatura

Objective: to describe the state of art of the official hysteroscopy and review the evidence in relation to acceptance, tolerance and benefits. Methodology: search in the databases PUBMED, COCHRANE, LILACS using the terms Office Hysteroscopy in English and Spanish published in the last ten years, which were available in full text, in addition, the EMBASE database was searched with additional limits of meta-analysis or systematic review. Some management guides and other relevant articles were included from the bibliographic references of the initial searches. Conclusions: it is considered an effective procedure for the diagnosis and treatment of intrauterine pathology, it is minimally invasive and of high degree of safety with an adequate technique. It has been accepted and well tolerated by patients, even without requiring anesthesia. Abbreviations: HUA, abnormal uterine bleeding; HO, official hysteroscopy.

Office Hysteroscopy: TROPHYscope CAMPO Compact Hysteroscope (®): Manufacturer: KARL STORZ, Tuttlingen, Germany.

In the early 1990s, outpatient procedures have increased in importance in gynecology since advances in technology and techniques made hysteroscopy less painful and less invasive [1, 2]. A major point for office hysteroscopy (“See and Treat Hysteroscopy”) is that there is no need to use a speculum. A new atraumatic hysteroscopic technique, the so-called vaginoscopic, or no-touch technique was developed and the widespread saline solution as the preferred distension medium as an alternative for CO2. Nowadays, office hysteroscopy can be considered as the gold standard if it comes to the examination of the uterine cavity. In fact, it is overcoming the significant restrictions of intrauterine diagnostic curettage [2]. The above-mentioned “See and Treat” concept is what patients are asking for. They consult a gynecologist with their issue and want to leave the office without the problem. For that purpose, the physician has to invest in extracurricular training and equipment to perform ambulatory hysteroscopy [1] (Fig. 1). Fig. 1 The TROPHYscope® However, modern office hysteroscopy benefits from the use of hysteroscopes with an outer diameter of less than 5 mm which can be used for diagnostics and minor operative procedures. Those hysteroscopes also eliminate the need to dilate the cervical canal which leads only to minimal discomfort for the patient. The new TROPHYscope® CAMPO Compact Hysteroscope from KARL STORZ, Tuttlingen, Germany, is specially designed for the above-mentioned purpose. It is based on a 2 mm HOPKINS® rod lens system with an integrated inflow channel. A continuous flow sheath or an operating sheath is positioned either in an active or passive position on the TROHPYscope®. At the start of the intervention, the primary access into the uterine cavity is carried out with an outer diameter of 2.9 mm, only, the corresponding sheath in the passive position. This small diameter facilitates the introduction of the hysteroscope into the uterine cavity and minimizes discomfort of the patient. It is advantageous for the examination of infertility patients and nullipara, as well as postmenopausal patients. If there is a need to clean the cavity (need for continuous flow), then further dilation up to 3.7 mm can be done by pushing the continuous flow sheath forward into the cavity guided by the telescope. For minor interventions, the extra operating sheath (overall diameter of 4.4 mm) with working channel for 5 Fr. instruments is used. For visualization in hysteroscopy a compact, versatile and portable system like the TELE PACK X LED is ideal for the gynecologists’ office. This system includes a 15″ LCD TFT-monitor, a camera, a light source, and a module for data processing as well as data management via USB or SD card [2]. As mentioned above, hysteroscopic procedures require distension of the uterine cavity. The most common medium in use is saline solution [2]. Saline solution offers a neutral vision of the uterine cavity, permits specific evaluation of the endometrial pathologies, and offers the possibility to work with bipolar electrodes. With an electronic irrigation and suction pump like the HAMOU® ENDOMAT, a pressure- and flow-controlled constant intrauterine distension is provided [3] (Fig. 2). Fig. 2 Tele pack + LED-System Nowadays, hysteroscopy is the gold standard for evaluation and treatment of intrauterine pathologies. But as a matter of fact, it is still not widely used in daily practice. The major reason for this is the lack of teaching in hysteroscopy during conventional medical training. Furthermore, the conviction of the gynecologist and the patient that an office hysteroscopy, without anesthesia, may be more painful leads to interventions favoring the so-called traditional approach [2]. Traditional surgery and office surgery are no longer mutually incompatible. Indeed, they have undergone a Hegelian synthesis. Both interventions are complementary to each other. The pathology itself distinguishes if traditional surgery or office surgery is appropriate as many diseases that can be treated hysteroscopically and can be done within an ambulatory setting [2]. Most women who have undergone an office hysteroscopy are satisfied with the procedure, and prepared to recommend it or undergo this experience again if necessary [4].

Noncardiogenic Pulmonary Edema from Massive Irrigation Fluid Absorption During Hysteroscopic Myomectomy: A Case Report

Background: Gynecological hysteroscopy is a relatively safe procedure, used for diagnosis and treatment of intrauterine pathologies with a low percentage of complications. Some complications may be life threatening. Case presentation: An otherwise healthy 44-year-old woman presented for hysteroscopic myomectomy under spinal anesthesia. A roller pump and a morcellator - type hysteroresectoscope were used along with normal saline as the distending solution with a perfusion pressure of 100 mmHg. Within 40 minutes, she complained of chest discomfort and presented tachypnea, tachycardia, hypertension and low oxygen saturation unresponsive to bag and mask ventilation with 100% oxygen. Massive facial edema developed rapidly. Orotracheal intubation was performed and pink frothy fluid came out of the ET. Fluid overload was suspected as the most likely diagnosis and the hysteroscopy was discontinued. Laboratory findings revealed severe respiratory acidosis and hypoxemia. She was treated aggressively with positive pressure ventilation, IV bicarbonate, diuretic and inotropic perfusions. A thorax x-ray confirmed the presence of massive pulmonary edema. After a highly negative fluid balance, the respiratory parameters improved very rapidly and she was extubated in the ICU 7 hours later Discussion: Fluid overload due to absorption of irrigation fluid is seen in approximately 0, 2% of patients. Hypervolemic syndrome and hyperchloremic metabolic acidosis have been reported in NS overload. In this case, a positive fluid balance of almost 6.5 l of NS was calculated; this was not identified before due to an error in the assembly of the circuit and bypass of the alarms thus leading to non-cardiogenic pulmonary edema, anasarca, respiratory acidosis, hypocalcaemia, coagulation and hemoglobin dilution, which resolved with forced diuresis and cardiopulmonary support. She was discharged after 7 days of the procedure. Conclusion: General anesthesia and sedation can mask symptoms of irrigation fluid absorption. Anesthesiologists must monitor fluid balance and perfusion pressure, of the irrigation fluid as well as keep an open communication with the surgeon at all times to avoid this type of events. The use of normal saline is not without life threatening complications.