Key drivers of hysterectomy among women of reproductive age in three states in India: comparative evidence from NFHS-4 and NFHS-5.

PURPOSE: According to the 4th and 5th rounds of National Family Health Survey (NFHS), there is high prevalence of hysterectomies in the three states of Andhra Pradesh Telangana and Bihar. The three said states have more than double the number of hysterectomies taking place than the national average. Our purpose is to analyse whether these rates are increasing, decreasing or have stabilized and their reasons thereof. Such an analyses will help the policy makers in recommending good clinical practices within their states. MATERIAL AND METHODS: We used data from NFHS-4 (2015-16) and NFHS-5 (2019-2021) rounds. We calculated the differences in predicted probabilities for various factors, performed a Fairlie Decomposition analyses to quantify the positive and negative contributors in the prevalence of hysterectomy across the three states over two time points, and assessed the association of various socio-demographic characteristics to hysterectomy through a multilevel logistic regression model. RESULTS AND CONCLUSION: The results show that out of a total of 80,976 eligible respondents from the states under study, 5826 respondents self-reported that they had a hysterectomy done. It was found that older age, living in rural areas, belonging to other backward classes and higher wealth quintile, and higher parity positively contributed to the increased prevalence of hysterectomies in the three states. Higher educational attainment and previous use of family planning methods acted as protective factors. Characteristics at the household level had the highest intra-class correlation value in the prevalence of hysterectomy among women, followed by the Primary Sampling Unit and District levels, indicating high clustering in the prevalence of hysterectomy at the household level in all three states. Heavy menstrual bleeding/pain was the leading cause of hysterectomies in all three states, followed by fibroids/cysts in Andhra Pradesh and Telangana and Uterine disorder/ prolapse in Bihar. Over 80% of hysterectomies took place in the private hospitals. RECOMMENDATIONS: The study recommends better, more efficient and accountable hysterectomy surveillance to ensure more sustainable woman's reproductive health services in India. Government should adopt and implement standard regulatory guidelines to prevent provider-driven avoidable hysterectomies. Moreover, we recommend informing primary care professionals about the long-term health effects of hysterectomy and promoting alternate therapies for treating uterine fibroids and heavy bleeding.

Guideline No. 447: Diagnosis and Management of Endometrial Polyps.

OBJECTIVE: The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps. TARGET POPULATION: All patients with symptomatic or asymptomatic endometrial polyps. OPTIONS: Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice. OUTCOMES: Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp. BENEFITS, HARMS, AND COSTS: The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps. EVIDENCE: The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows. TWEETABLE ABSTRACT: Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary. SUMMARY STATEMENTS: RECOMMENDATIONS.

Intrarectal Foley catheter-assisted high-intensity focused ultrasound ablation for benign uterine diseases beyond the treatment region.

OBJECTIVE: To evaluate the feasibility of using an intrarectal Foley catheter during ultrasound-guided high-intensity focused ultrasound (US-HIFU) in patients with benign uterine diseases of the posterior wall beyond the HIFU therapeutic range. METHODS: Patients were treated with US-HIFU and lesion changes were monitored using contrast-enhanced MRI from June 2020 to September 2021. A Foley catheter was inserted into the rectum to facilitate a successful US-HIFU ablation. Complications and lesion responses were recorded during the treatment and follow-up. RESULTS: Thirteen patients with 14 lesions beyond the device's treatable area were enrolled. The average placement time and insertion depth of the intrarectal Foley catheter was 7.6 ± 2.7 min and 23.2 ± 7.6 cm, respectively. A median of 50 mL degassed water was injected into the Foley catheter balloon. All 14 lesions were successfully pushed into a treatable area and subjected to HIFU. The average treatment time, irradiation time, and total therapeutic energy of HIFU were 44.2 ± 17.3 min, 394.4 ± 295.7 s, and 73.3 ± 46.6 kJ, respectively. The mean non-perfusion volume (NPV) in all treated lesions was 23.2 ± 19.2 cm3, and the mean NPV ratio was 57.8 ± 16.9%. Major complications were not observed. CONCLUSION: Intrarectal Foley catheter-assisted US-HIFU is effective and safe. Its clinical application could benefit patients with benign uterine diseases outside the HIFU therapeutic range.

Efficacy of autologous platelet-rich plasma in preventing adhesion reformation following hysteroscopic adhesiolysis: a randomized controlled trial.

RESEARCH QUESTION: What is the efficacy of platelet-rich plasma (PRP) in reducing adhesion reformation in women with moderate to severe intrauterine adhesions (IUA)? DESIGN: In this randomized controlled trial, women with moderate-to-severe IUA were recruited between November 2019 and June 2021 from a university hospital and randomized into the PRP or control group. The PRP group was treated using an intrauterine-suitable balloon combined with PRP infusion following hysteroscopic adhesiolysis, whereas the control group received only the former intervention. The reductions in adhesion scores from before to after surgery and the adhesion reformation rate were analysed. RESULTS: A total of 123 participants successfully completed the study (PRP group, 63; control group, 60). Age, pregnancy history, menstrual score and American Fertility Society score before surgery were not significantly different between the two groups. At the second-look hysteroscopy, the PRP group had a significantly greater reduction in adhesion score than the control group (7 versus 6, respectively; P = 0.027). The postoperative adhesion reformation rates in the PRP group and the control group were 20.6% and 30.0%, respectively (risk ratio 0.69, 95% confidence interval 0.27-1.38, P = 0.232; number needed to treat 10.6). CONCLUSIONS: Intrauterine PRP infusion seems to be beneficial in reducing postoperative adhesion reformation following hysteroscopic adhesiolysis.

The efficacy of auto-cross-linked hyaluronic acid gel in addition to oestradiol and intrauterine balloon insertion in the prevention of adhesion reformation after hysteroscopic adhesiolysis.

RESEARCH QUESTION: What is the efficacy of auto-cross-linked hyaluronic acid gel use in preventing adhesion reformation after intrauterine adhesiolysis? DESIGN: This was a single-centre, double-blind randomized controlled trial. RESULTS: In total 171 participants successfully completed the study (84 in the treatment group and 87 in the control group). There was no significant difference in pre-operative variables between the two groups. The primary outcome measure was the adhesion reformation rate at second-look and third-look hysteroscopy. At second-look hysteroscopy, there was no significant difference in adhesion recurrence rate between the treatment group (20.2%, 17/84) and the control group (23.0%, 20/87; P = 0.662). At third-look hysteroscopy, there was also no significant difference in adhesion recurrence rate between the treatment group (9.5%, 8/84) and the control group (11.5%, 10/87; P = 0.675). The secondary outcome measure was the median American Fertility Society (AFS) score, which was not significantly different at second-look hysteroscopy 4 weeks after surgery between the treatment group (0, range 0-4.0) and the control group (0, range 0-4.0; P = 0.475), and at third-look hysteroscopy 8 weeks after surgery between the treatment group (0, range 0-3.5) and the control group (0, range 0-4.0; P = 0.965). Regarding the menstrual flow improvement rate 3 months post-operatively, there was no significant difference between the treatment and control groups (67.9% versus 64.4%; P = 0.630). CONCLUSIONS: The application of auto-cross-linked hyaluronic acid gel does not seem to reduce the incidence and severity of intrauterine adhesion recurrence or affect the menstrual pattern after hysteroscopic removal of mild to moderate intrauterine adhesions.

Vaginal repair of cesarean section scar defects: Preoperative hysteroscopic evaluation.

INTRODUCTION: Cesarean section scar defects (CSDs) are one of the long-term complications following cesarean section. They can be detected by transvaginal sonography, hysterosalpingography, sonohysterography and magnetic resonance imaging (MRI). Hysteroscopy is frequently used in evaluating endometrial disease. However, the description of CSDs by hysteroscopy is very limited. Only a few papers about hysteroscopy evaluation have been published. This is an exploratory study to compare hysteroscopic findings with myometrial thickness and post-surgical outcomes. MATERIAL AND METHODS: From February 2019 to December 2020, 143 women with CSDs were enrolled in the observational study. All women suffered from abnormal uterine bleeding and were evaluated in a standardized way with hysteroscopy before vaginal surgery. Dome-shaped CSDs could be clearly observed in all patients under hysteroscopy. We recorded the pictures of each patient under hysteroscopy and classified them. All patients underwent outpatient review at 3 and 6 months after surgery to obtain menstrual information and CSD scar size by MRI or transvaginal sonography. RESULTS: Pale mucosae in the defect were meager endometrial lining covering the surface of muscle layer, cyst lesions were some cyst lesions in the defect, increased local vascularization was a vascular tree with branching and irregular vascular distribution in defect, polypoid lesions were polypoid lesions in the defect, and serrated niches were two niches at the anterior uterine isthmus. The features of the CSDs observed under hysteroscopy were identified as five phenotypes: pale mucosae (90/143, 62.9%), cyst lesions (23/143, 16.1%), polypoid lesions (19/143, 13.3%), increased local vascularization (27/143, 18.9%) and serrated niches (7/143, 4.9%). The most common finding in scar defects under hysteroscopy was pale mucosae in the CSD. The results suggest that patients with increased local vascularization and serrated niches have a high risk of thinner residual myometrium before vaginal repair (p < 0.05). However, there was no significant difference in menstrual duration or in the outcome of vaginal repair for CSDs between these five phenotypes (p > 0.05). CONCLUSIONS: Patients with the abnormal blood vessel or serration phenotypes of defects under hysteroscopy may have a thinner residual myometrium. The phenotypes of hysteroscopic findings of CSDs have no correlation with the outcome of repair.

Focus on the Primary Prevention of Intrauterine Adhesions: Current Concept and Vision.

Intrauterine adhesion (IUA), and its severe form Asherman syndrome (Asherman's syndrome), is a mysterious disease, often accompanied with severe clinical problems contributing to a significant impairment of reproductive function, such as menstrual disturbance (amenorrhea), infertility or recurrent pregnancy loss. Among these, its correlated infertility may be one of the most challenging problems. Although there are many etiologies for the development of IUA, uterine instrumentation is the main cause of IUA. Additionally, more complicated intrauterine surgeries can be performed by advanced technology, further increasing the risk of IUA. Strategies attempting to minimize the risk and reducing its severity are urgently needed. The current review will expand the level of our knowledge required to face the troublesome disease of IUA. It is separated into six sections, addressing the introduction of the normal cyclic endometrial repairing process and its abruption causing the formation of IUA; the etiology and prevalence of IUA; the diagnosis of IUA; the classification of IUA; the pathophysiology of IUA; and the primary prevention of IUA, including (1) delicate surgical techniques, such as the use of surgical instruments, energy systems, and pre-hysteroscopic management, (2) barrier methods, such as gels, intrauterine devices, intrauterine balloons, as well as membrane structures containing hyaluronate-carboxymethylcellulose or polyethylene oxide-sodium carboxymethylcellulose as anti-adhesive barrier.

Prevention of de novo adhesion formation in patients with Asherman's syndrome.

OBJECTIVE: To summarize recent data and knowledge of secondary prevention of the recurrence of intrauterine adhesions in patients with Ashermans syndrome. METHODS: Analysis of literature evidence and clinical experience of the authors. RESULTS: Ashermans syndrome is iatrogenic disease with problematic therapy. One of the basic issues is a need for repeated surgical interventions since the recurrence of adhesions is very frequent. Secondary prevention is a crucial factor for successful therapy in these patients. The methods applied include second--look hysteroscopy, hormonal treatment and different types of barriers. To compare their efficacy is difficult and the results of meta-analysis are contradictory. CONCLUSION: There are many different possibilities of secondary prevention of the recurrence of intrauterine adhesions; unfortunately, none of them is perfect. The usage of solid or semi-solid barriers in combination with the support of endometrium regeneration with hormonal therapy seems most reasonable.

Secondary Prevention of Intrauterine Adhesions Following Hysteroscopic Surgery in Women With Asherman Syndrome: Is Something Better Than Nothing?

Asherman syndrome is a reproductive disorder characterized by intrauterine adhesions and amenorrhea, infertility, abnormal placentation, or pregnancy loss. Treatment of Asherman syndrome involves hysteroscopic lysis of adhesions. Many surgeons utilize postoperative measures such as hormone therapy, solid mechanical devices, or barrier gels to prevent recurrent adhesions in this setting. However, there is limited high-quality evidence to support their use. Additional research is needed on the safety and efficacy of these commonly used methods to guide patient care.

Laparoscopic correction of isthmocele combined with ventrosuspensios of uterus.

OBJECTIVE: To describe a case history of a patient after two caesarean sections, planning another pregnancy. Due to the dehiscent lower uterine segment, surgical correction of the defect was performed. Performance followed by an unplanned pregnancy five weeks after the operation. DESIGN: Case report. SETTING: Department of Obstetrics and Gynaecology, Hospital in Frýdek-Místek. CASE REPORT: We present a case of a 31-year-old third-graders, anamnestically after two caesarean sections, which were performed laparoscopical correction of isthmocoele in our department. Our patient was diagnosed with six weeks old intrauterine pregnancy only eleven weeks after surgery. The gravidity was successfully completed in the 38th week of pregnancy by the planned caesarean section with finding of a solid lower uterine segment. Whole duration of the pregnancy was uncomplicated. CONCLUSION: Women, after previous surgery of the uterus, are exposed to complications such as nidation disorders, placental disorders, risk of uterine rupture etc. during future pregnancy and childbirth. We want to show possible advantage of laparoscopic isthmocoele resection in combination with ventrosuspension of uterus.

No. 377-Hysterectomy for Benign Gynaecologic Indications.

OBJECTIVE: To assist physicians performing gynaecologic surgery in decision making surrounding hysterectomy for benign indications. INTENDED USERS: Physicians, including gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers. TARGET POPULATION: Adult women (18 years and older) who will undergo hysterectomy for benign gynaecologic indications. OPTIONS: The approach to hysterectomy and utility of concurrent surgical procedures are reviewed in this guideline. EVIDENCE: For this guideline relevant studies were searched in the PubMed, Medline, and Cochrane Library databases. The following MeSH search terms and their variations for the last 5 years (2012-2017) were used: vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy, and total vaginal hysterectomy. VALIDATION METHODS: The content and recommendations were drafted and agreed upon by the principal authors and members of the Gynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2). The Summary of Findings is available upon request. BENEFITS, HARMS, AND COSTS: Hysterectomy is common, yet surgical practice still varies widely among gynaecologic physicians. This guideline outlines preoperative and perioperative considerations to improve the quality of care for women undergoing benign gynaecologic surgery. GUIDELINE UPDATE: This Society of Obstetricians and Gynaecologists of Canada clinical practice guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. SPONSORS: This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: RECOMMENDATIONS.

A Novel Ultrasound-Guided Technique for Hysteroscopic Adhesiolysis in High-Risk Patients.

Hysteroscopy is a common gynecologic surgical procedure. Certain diagnoses, notably intrauterine adhesions and cervical stenosis, make hysteroscopy more complicated because of an increased likelihood of complications. Three patients, 1 with cervical stenosis and 2 with Asherman syndrome, underwent ultrasound (US)-guided adhesiolysis. Access to the uterine cavity was obtained by either direct balloon-aided dilation or the US-guided Seldinger technique, followed by balloon-aided dilation to enter the endometrial cavity and disrupt intrauterine/intracervical adhesions. In this case series, we describe a novel approach of using US-guided balloon dilation to safely and effectively treat intrauterine adhesions and to decrease the risk of perforation.

Standardization of laparoscopic extrafascial hysterectomy: anatomic considerations to protect the ureter.

PURPOSE: To describe the procedure of laparoscopic extrafascial hysterectomy to avoid ureter injury. METHODS: Data were obtained from: (1) anatomic study of ten fresh female cadavers to measure the distance between the point where the ureter and uterine artery cross and the level of section of the ascending branch of the uterine artery during extrafascial dissection of the uterine pedicle and uterosacral ligament (Paris School of Surgery). The Wilcoxon test was used to compare measurements within each subject. P < 0.05 was considered to denote significance; (2) prospectively collected clinical data from women undergoing laparoscopic extrafascial hysterectomy from July 2006 to March 2014 at Poissy University Hospital, to describe the laparoscopic extrafascial hysterectomy technique with analysis of surgical complications using the Clavien-Dindo classification. RESULTS: Anatomic study: The mean (SD) distance between the point where the ureter and uterine artery cross and the level of the section of the ascending branch of the uterine artery were: 11.6 mm (5.2) in neutral position and 25 mm (7.5) after pulling the uterus laterally; and 25mm (8.9) after sectioning the ascending portion of the uterine pedicle and 38.6 mm (4.5) after complete uterine artery pedicle dissection through the uterosacral ligaments. After release of the ureter, the curve in front of the uterine artery disappeared. Clinical laparoscopic study: Sixty-eight patients underwent laparoscopic extrafascial hysterectomy. No ureteral complications occurred. CONCLUSION: Laparoscopic extrafascial hysterectomy is a safe and feasible procedure. Combined lateralization and elevation of the uterus, section of the ascending branch of the uterine artery, and its extrafascial dissection along the uterosacral ligament contribute to protecting the ureter during the procedure.

Adverse effect analysis of high-intensity focused ultrasound in the treatment of benign uterine diseases.

OBJECTIVE: To retrospectively analyze the adverse effects of high-intensity focused ultrasound (HIFU) in management of benign uterine diseases. MATERIALS AND METHODS: From 2011 to 2017, 27,053 patients with benign uterine diseases were treated with HIFU in 19 centers in China. Among them, 17,402 patients had uterine fibroids, 8434 had adenomyosis, 876 had caesarean scar pregnancies, and 341 had placenta accreta. RESULTS: The median age, height, weight, BMI of the patients was 42 years, 158 mm, 56 kg, 22.5 kg/cm2, respectively. After HIFU treatment, 13,170 adverse events were observed. Based on society of interventional radiology classification system, these adverse events were classified as Class A (47.5030%), Class B (0.7947%), Class C (0.3327%), and Class D (0.0518%). The rate of major adverse effects (Class C&D) was 0.3844%. Major adverse effects include skin burn, leg pain, vaginal discharge or bleeding, urinary retention, acute cystitis, intrauterine infection, bowel injury, acute renal failure, deep vein thrombosis, pubic symphysis injury, post-HIFU thrombocytopenia, sciatic nerve injury, and hydronephrosis. In 2011, the annual rate of major adverse effects was 0.9565%; the incidence decreased to 0.2852% in 2017. No significant difference was observed in the rates of major adverse effects between patients with uterine fibroids, adenomyosis and placenta accreta. CONCLUSIONS: Based on the results with low rate of major adverse effects from multiple centers, we concluded that HIFU is safe in treating patients with benign uterine diseases. With development of this technique and more experience on the part of the physicians, the rates of the major adverse effects will be further lowered.

Hysteroscopic Isthmoplasty: Step-by-Step Technique.

STUDY OBJECTIVE: To demonstrate our technique for surgical hysteroscopy performed with a standard-size resectoscope or miniresectoscope in 3 cases of isthmocele. DESIGN: Step-by-step demonstration of the technique using slides, pictures, and video (educative video) (Canadian Task Force classification III). SETTING: Isthmocele is a characteristic semidiverticular anomaly of the anterior isthmic wall of the uterus, located at the site of a previous cesarean delivery scar. The etiopathogenesis of isthmocele remains poorly understood, although several hypotheses have been proposed. Factors that may possibly play a role in niche development include a very low incision through cervical tissue, inadequate suturing technique during closure of the uterine scar, surgical interventions that increase adhesion formation, and patient-related factors that impair wound healing or increase inflammation or adhesion formation. The treatment of isthmocele focuses on relieving symptoms (i.e., postmenstrual spotting, suprapubic pelvic pain, dysmenorrhea, dyspareunia, and infertility), and, consequently, asymptomatic cases should not be treated. Various surgical approaches have been described to treat isthmocele-related symptoms, including hysteroscopy, laparoscopy, vaginal, robotic, and combined techniques. INTERVENTION: Our local Institutional Review Board approved the study protocol. The procedures were performed in operative room using a 26 Fr and 16 Fr continuous-flow resectoscope under general anesthesia. The surgical technique involves resection of the fibrotic tissue of the lower margin and then the upper margin of the pouch using a cutting loop, until the underlying muscular tissue is reached, followed by resection of the inflamed and necrotic tissue of the base of the pouch. Similar surgical maneuvers are performed on the contralateral side (right anterolateral wall) for complete ablation of the isthmic region (inverted ablation). CONCLUSION: According to the most recent literature, hysteroscopic hystmoplasty appears to be a safe and effective treatment option in cases of isthmocele with a niche at least 2 mm deep and a residual myometrial thickness of at least 3 mm to improve postmenstrual bleeding. When residual myometrial thickness is <3 mm, the hysteroscopic approach is not recommended, mainly because of the risk of bladder injury. In these symptomatic cases, laparoscopic or vaginal repair may be considered.

Hysterectomy in Poland between 2011 and 2016. Changing trends in the surgical approach to hysterectomy.

OBJECTIVES: In Poland, approximately 35,000 women a year undergo hysterectomy. The surgical approach may vary depending on the indications and experience of the operator and advances in laparoscopic surgical techniques. The aim of the present study was to analyze trends in the use of various types of hysterectomy in Poland between 2011 and 2016. Summary values were given as numbers and percentages. Annual incidence of procedures and identify factors which influence these changes in gynecological practice. MATERIAL AND METHODS: Data on hysterectomy procedures performed between 2011 and 2016 in Poland acquired from the National Health Fund reports were extracted and analyzed. Summary values were given as numbers, percentages and rate ratios (RR). Annual incidence of procedures and identify factors that influence these changes in gynecological practice. RESULTS: Between 2011 and 2016, 215,744 women were treated by hysterectomy in inpatient settings. The total number of those procedures in analyzed period decreased by 11.5%; the incidence rate dropped by 2.15 per 100,000 women. A significant increase in laparoscopic procedures was observed (RR = 3.85; CI: 3.57-4.16; p < 0.001) along with a decrease in the number of abdominal operations (RR = 0.82; CI: 0.81-0.83; p < 0.001). CONCLUSIONS: Surgical technique advances, introduction of intrauterine systems and hormonal therapy, as well as recommendations of international institutions have brought about changes in the methods and frequency of hysterectomy. The laparoscopic approach has been gaining popularity since it is beneficial both for patients and public health system. However, the percentage of advanced minimally invasive hysterectomies is still low in Poland in comparison to other countries.

Complications in operative hysteroscopy - is prevention possible?

Operative hysteroscopy in a hospital setting has revolutionized surgical treatment of benign uterine disorders. It is minimally invasive, cost- and time-effective, and may spare patients major surgical interventions. Operative hysteroscopy in a day-case hospital setting is regarded as a safe and well-tolerated procedure with low complication rates. However, prevention of adverse events is crucial in daily practice to optimize patient care. Complications in operative hysteroscopy can be divided into early complications, including bleeding, uterine perforation, infection and fluid overload, or late complications and suboptimal outcomes, such as incomplete resection and intrauterine adhesions. Awareness and knowledge of management of adverse events as well as the use of possible preventative measures will increase the quality and safety of hysteroscopic surgery. The present commentary focuses on these issues as an up-to-date basis for everyday clinical practice.

In Search for the Best Minimally Invasive Hysterectomy Approach for the Large Uterus: A Review.

Review of literature is conducted to determine the best minimally invasive hysterectomy (MIH) route for large uterus, identify preoperative considerations and describe alternative techniques to power morcellation. Studies after 2010 revealed multiple MIH approaches. Vaginal hysterectomy is preferred over laparoscopic and laparoscopic assistance with less operative time and hospital cost. In morbidly obese patients with large uteri, total laparoscopic hysterectomy is superior to vaginal hysterectomy with lesser odds of blood transfusion and lower length of hospital stay. Although MIH for the large uterus is feasible, many questions remain unanswered. Well-designed multicenter prospective trial incorporating clinical pathways to compare outcomes is needed.

Hysteroscopy for Abnormal Uterine Bleeding and Fibroids.

Operative hysteroscopy is a safe and effective minimally invasive treatment option for submucosal and intramural leiomyomas. We discuss preoperative evaluation, fluid management, postoperative complications, preventative measures, and hysteroscopic outcomes. Technical instructions and tips for successful hysteroscopy, as well as the various equipment options most commonly utilized in the United States, are also reviewed.

Intrauterine adhesion prevention after hysteroscopy: a systematic review and meta-analysis.

BACKGROUND: Despite years of studies evaluating prevention strategies for intrauterine adhesion formation after operative hysteroscopy, it is still unclear which strategies are most effective. OBJECTIVE: The objective of the study was to perform a systematic review and meta-analysis to evaluate the effectiveness of postoperative prevention strategies on intrauterine adhesion formation following operative hysteroscopy. STUDY DESIGN: Literature searches were conducted in MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases. Inclusion criteria were published randomized controlled clinical trials from 1989 to 2014 comparing any postoperative preventative measures of intrauterine adhesion after hysteroscopy. The main outcome measure was a reduction in postoperative intrauterine adhesion. Heterogeneity of the studies was evaluated using a Q test and an I(2) index. Analyses were performed using a random-effects model with outcome data reported as relative risk with 95% confidence interval. RESULTS: Twelve studies were included in the systematic review. Eight studies compared similar treatment methods and were included in the meta-analysis. Three studies evaluated hyaluronic acid gel, of which 2 reported a significant decrease in intrauterine adhesion with treatment. The meta-analysis demonstrated a significant reduction of intrauterine adhesion when using hyaluronic acid gel. Two studies evaluated polyethylene oxide-sodium carboxymethylcellulose gel, 1 of which demonstrated a decrease in intrauterine adhesion with treatment. A meta-analysis showed a significant reduction of intrauterine adhesion with polyethylene oxide-sodium carboxymethyl cellulose gel. However, these 3 studies demonstrating a benefit of the gels in preventing adhesion formation were all conducted by the same research group. Other research groups have not confirmed these results. A sensitivity analysis excluding these trials from this single group demonstrated no benefit to adhesion prevention with either gel formation. Three studies investigated oral estrogen therapy after hysteroscopy and found no difference in intrauterine adhesion. A meta-analysis showed no decrease in intrauterine adhesion with estrogen therapy after hysteroscopy. Data were lacking to perform metaanalyses on the use of intrauterine balloon, intrauterine device, and other adhesion prevention barriers in preventing intrauterine adhesion. CONCLUSION: There was a lack of definitive evidence to conclude that any treatment is effective in preventing posthysteroscopy uterine adhesion formation. The available literature has significant heterogeneity and a high risk of bias, making any definitive conclusions difficult.