Hysteroscopy needs of indigenous communities in Northern Quebec: a retrospective cohort study.

We aimed to determine the surgical output for patients from Nunavik undergoing transfer to an urban centre for hysteroscopy, and associated costs. We performed a retrospective chart review of all patients from the 14 villages of Nunavik transferred for hysteroscopic surgery from 2016 to 2021. Diagnoses, surgical intervention, and nature of the procedure were all extracted from the patient charts, and costs/length of stay obtained from logisticians and administrators servicing the Nunavik region. Over a 5-year period, 22 patients were transferred from Nunavik for hysteroscopy, of which all were elective save one. The most common diagnosis was endometrial or cervical polyp and the most common procedure was diagnostic hysteroscopy. The average cost for patient transfer and lodging to undergo hysteroscopy in Montreal ranged from $6,000 to $15,000 CDN. On average, 4-5 patient transfers occur annually for hysteroscopy, most commonly for management of endometrial polyps, at a cost of $6,000 to $15,000 CDN, suggesting the need to investigate local capacity building in Nunavik and assess cost-effectiveness.

Mobile Hysteroscopy With the Use of a Smartphone as a Cost-Effective, Diagnostic Technique.

BACKGROUND: Smartphone technology can be adapted to promote cable-free, wireless, and cost-effective diagnostic mobile office hysteroscopy. INSTRUMENT: We developed a new cable-free setup by coupling a rigid 30°, 2-mm-diameter hysteroscope to a smartphone using a commercially available adapter and using a portable and rechargeable light-emitting diode cold light source. The new setup cost is considerably lower compared with that of a typical endoscopic tower. EXPERIENCE: We performed both standard hysteroscopy and hysteroscopy using the new portable setup in 40 patients for a variety of benign gynecologic indications. The operating time was compared between the two methods, as was the pain perceived by the patients. Videos from the two setups were blindly reviewed and scored by experts regarding image resolution, brightness, color, and overall image quality. The new technique was acceptable for diagnosis in 97.5% of the videos. CONCLUSION: We report a promising initial experience using a smartphone to provide a convenient, cable-free, low-cost, office hysteroscopy system.

Hysteroscopic and aspiration biopsies in the histologic evaluation of the endometrium, a comparative study.

This study aimed to compare the quality of histological endometrial samples collected through Pipelle aspiration and hysteroscopic biopsies to assess the agreement between these 2 biopsies in the histological diagnosis of malignancy and to compare the costs of both biopsies.This was a cross-sectional study. Forty-five women were biopsied, first using Pipelle and immediately after using hysteroscopy. The material collected was sent for analysis, and hysteroscopy was considered the gold standard. The results were divided into the following 3 categories: normal (atrophic, proliferative, and secretory endometrium); polyps; and malignancies. We report the agreement between Pipelle and hysteroscopy in the diagnosis of malignancy and compare their costs.The study showed that while analyzing endometrial malignancies, Pipelle sampling had 100% sensitivity and specificity. In the detection of polyps, Pipelle sampling showed 26.1% sensitivity, 88.9% specificity, 75% positive predictive value, 48.5% negative predictive value, and 53.7% accuracy. Agreement with hysteroscopy in the diagnosis of malignancy was 100%. The Pipelle device costs 27 times less than hysteroscopic biopsy for health insurance companies. This cost is 13.7 times lower in the Brazilian Unified Health System.Endometrial biopsies using the Pipelle have a high accuracy for endometrial cancer and a low accuracy for polyps. We detected 100% agreement between the reports of Pipelle and hysteroscopy with regard to malignancy. Pipelle is the most cost-effective method of endometrial biopsy.

Impact of body mass index on utilization of selected hospital resources for four common surgical procedures.

BACKGROUND: Evidence about the impact of obesity on surgical resource consumption in the Australian setting is equivocal. Our objectives were to quantify the prevalence of obesity in four frequently performed surgical procedures and explore the association between body mass index (BMI) and hospital resource utilization including procedural duration, length of stay (LOS) and costs. METHODS: A retrospective cohort study of patients undergoing four surgical procedures at a tertiary referral centre in New South Wales, between 1 January 2016 and 31 December 2016, was conducted. The four surgical procedures were total hip replacement, laparoscopic appendectomy, laparoscopic cholecystectomy and hysteroscopy with dilatation and curettage. Surgical groups were stratified according to BMI category. RESULTS: A total of 699 patients were included in the study. The prevalence of obesity was significantly higher than local and national population estimates for all procedures except appendectomy. BMI was not associated with increased hospital resource utilization (procedural, anaesthetic or intensive care stay duration) in any of the four surgical procedures examined after controlling for age, gender and complexity. For other outcomes of hospital resource utilization (LOS and cost), the relationship was inconsistent across the four procedures examined. A high BMI was positively associated with higher LOS, medical costs and allied health costs in those who underwent an appendectomy, and critical care costs in those who underwent laparoscopic cholecystectomy. CONCLUSION: Obesity was common in patients undergoing four frequently performed surgical procedures. The relationship between BMI and hospital resource utilization appears to be complex and varies across the four procedures examined.

The (cost) effectiveness of procedural sedation and analgesia versus general anaesthesia for hysteroscopic myomectomy, a multicentre randomised controlled trial: PROSECCO trial, a study protocol.

BACKGROUND: In women with abnormal uterine bleeding, fibroids are a frequent finding. In case of heavy menstrual bleeding and presence of submucosal type 0-1 fibroids, hysteroscopic resection is the treatment of first choice, as removal of these fibroids is highly effective. Hysteroscopic myomectomy is currently usually performed in the operating theatre. A considerable reduction in costs and a higher patient satisfaction are expected when procedural sedation and analgesia with propofol (PSA) in an outpatient setting is applied. However, both safety and effectiveness - including the necessity for re-intervention due to incomplete resection - have not yet been evaluated. METHODS: This study is a multicentre randomised controlled trial with a non-inferiority design and will be performed in the Netherlands. Women > 18 years with a maximum of 3 symptomatic type 0 or 1 submucosal fibroids with a maximum diameter of 3.5 cm are eligible to participate in the trial. After informed consent, 205 women will be randomised to either hysteroscopic myomectomy using procedural sedation and analgesia with propofol in an outpatient setting or hysteroscopic myomectomy using general anaesthesia in a clinical setting in the operating theatre. Primary outcome will be the percentage of complete resections, based on transvaginal ultrasonography 6 weeks postoperatively. Secondary outcomes are cost effectiveness, menstrual blood loss (Pictorial blood assessment chart), quality of life, pain, return to daily activities/work, hospitalization, (post) operative complications and re-interventions. Women will be followed up to one year after hysteroscopic myomectomy. DISCUSSION: This study may demonstrate comparable effectiveness of hysteroscopic myomectomy under procedural sedation and analgesia versus general anaesthesia in a safe and patient friendly environment, whilst achieving a significant cost reduction. TRIAL REGISTRATION: Dutch trial register, number NTR5357 . Registered 11th of August 2015.

Effectiveness of Hysteroscopic Techniques for Endometrial Polyp Removal: The Italian Multicenter Trial.

STUDY OBJECTIVE: To compare the effectiveness and safety of different techniques of hysteroscopic polypectomy. DESIGN: Multicenter, prospective observational trial (Canadian Task Force classification II-2). SETTING: Nineteen Italian gynecologic departments (university-affiliated or public hospitals). PATIENTS: Consecutive patients suffering from endometrial polyps (EPs). INTERVENTIONS: Hysteroscopic polypectomy, as performed through different techniques. MEASUREMENTS AND MAIN RESULTS: Included in the study were 1404 patients (with 1825 EPs). The setting was an ambulatory care unit in 40.38% of the cases (567 women), of whom 97.7% (554) did not require analgesia/anesthesia. In the remaining 59.62% of women (837 women), the procedures were performed in an operating room under mild sedation, local or general anesthesia. Minor complications occurred in 32 patients (2.27%), without significant differences between the techniques used (p = ns). Uterine perforation occurred in 14 cases, all performed in the operating room with some kind of anesthesia, only 1 with a vaginoscopic technique and the remaining during blind dilatation (odds ratio [OR], 19.98; 95% confidence interval [CI], 1.19-335.79; p = .04). An incomplete removal of EPs was documented in 39 patients. Logistic regression analysis showed that a higher risk of residual EPs was associated with the use of a fiber-based 3.5-mm hysteroscope (OR, 6.78; 95% CI, 2.97-15.52; p <.001), the outpatient setting (OR, 2.17; 95% CI, 1.14-4.14; p = .019), and EPs located at the tubal corner (OR, 1.98; 95% CI, 1.03-2.79; p = .039). No association between incomplete EP removal and EP size or number was recorded (p = ns), as well as with the other variables evaluated. CONCLUSION: Outpatient polypectomy was associated with a minimal but significantly higher risk of residual EPs in comparison with inpatient polypectomy. Conversely, inpatient polypectomy was associated with a considerably higher risk of uterine perforation and penetration in comparison with office hysteroscopy. Because of lower intraoperative risks and higher cost-effectiveness, office hysteroscopy may be considered, whenever possible, as the gold standard technique for removing EPs.

Hysteroscopic Endometrial Polypectomy: Clinical and Economic Data in Decision Making.

STUDY OBJECTIVE: To compare the costs of hysteroscopic polypectomy using mechanical and electrosurgical systems in the hospital operating room and an office-based setting. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary referral hospital and center for gynecologic care. PATIENTS: Seven hundred and fifty-four women who underwent endometrial polypectomy between January 20, 2015, and April 27, 2016. INTERVENTIONS: Hysteroscopic endometrial polypectomy performed in the same-day hospital setting or office setting using one of the following: bipolar electrode, loop electrode, mechanical device, or hysteroscopic tissue removal system. MEASUREMENTS AND MAIN RESULTS: The various costs associated with the 2 clinical settings at Palagi Hospital, Florence, Italy were compiled, and a direct cost comparison was made using an activity-based cost-management system. The costs for using reusable loop electrode resection-16 or loop electrode resection-26 were significantly less expensive than using disposable loop electrode resection-27, the tissue removal system, or bipolar electrode resection (p = .0002). Total hospital costs for polypectomy with all systems were significantly less expensive in an office setting compared with same-day surgery in the hospital setting (p = .0001). Office-based hysteroscopic tissue removal was associated with shorter operative time compared with the other procedures (p = .0002) CONCLUSION: The total cost of hysteroscopic polypectomy is markedly higher when using disposable equipment compared with reusable equipment, both in the hospital operating room and the office setting. Same-day hospital or office-based surgery with reusable loop electrode resection is the most cost-effective approach in each settings, but requires experienced surgeons. Finally, the shorter surgical time should be taken into consideration for patients undergoing vaginal polypectomy in the office setting, owing more to patient comfort than to cost savings.

Management of persistent caesarean scar pregnancy after curettage treatment failure.

BACKGROUND: Caesarean scar pregnancy (CSP) is a late serious complication of caesarean section. The incidence of CSP has increased worldwide in recent years. Early diagnosis and prompt therapy are crucial to avoid catastrophic complications. There are various strategies for CSP treatment, but there is no consensus on the best management for CSP. Dilation and curettage (D&C) and hysteroscopy are common and effective treatments with their advantages and disadvantages. No in-depth study of the clinical effects of hysteroscopic management of CSP after D&C treatment failure has been conducted. The purpose of this study is to evaluate the effectiveness and safety of hysteroscopic removal of residual CSP tissue (persistent CSP) as a rescue after failed D&C management. METHODS: This is a retrospective clinical research study. Forty-five patients underwent operative hysteroscopy to remove the residual gestational tissue in the caesarean scar after failed D&C treatment. The clinical characteristics and outcomes of hysteroscopic surgeries of 45 CSP cases were investigated. All data analyses were conducted with SPSS 17.0. RESULTS: Forty-three CSP cases after unsuccessful curettage treatment were successfully treated by operative hysteroscopy. The estimated intraoperative blood loss was 20.00 (10.00-500.00) mL, the hysteroscopic operating time was 20.00 (15.00-45.00) min, the decline of serum ß-hCG the day after surgery was 71.91 ± 14.05%, the total hospitalisation time was 7.87 ± 2.26 days, the medical cost was 13,682.71 ± 3553.77 China Yuan (CNY), the time of bleeding after surgery was 7.42 ± 2.48 days, and the time of serum ß-hCG resolution after surgery was 13.84 ± 9.83 days. Follow-up after discharge demonstrated that there were no severe complications for any patients. CONCLUSIONS: Hysteroscopy therapy could treat persistent CSP effectively and safely after curettage treatment failure. Therapy should be individualised, and the risks and cost of the hysteroscopy procedure and anaesthesia must be considered and fully discussed with the patients before surgery.

Hysteroscopic polypectomy prior to infertility treatment: A cost analysis and systematic review.

The cost of fertility treatment is expensive and interventions that reduce cost can lead to greater efficiency and fewer embryos transferred. Endometrial polyps contribute to infertility and are frequently removed prior to infertility treatment. It is unclear whether polypectomy reduces fertility treatment cost and if so, the magnitude of cost reduction afforded by the procedure. The aim of this study was to determine whether performing office or operative hysteroscopic polypectomy prior to infertility treatment would be cost-effective. PubMed, Embase, and Cochrane libraries were used to identify publications reporting pregnancy rates after hysteroscopic polypectomy. Studies were required to have a polypectomy treatment group and control group of patients with polyps that were not resected. The charges of infertility treatments and polypectomy were obtained through infertility organizations and a private healthcare cost reporting website. These charges were applied to a decision tree model over the range of pregnancy rates observed in the representative studies to calculate an average cost per clinical or ongoing pregnancy. A sensitivity analysis was conducted to assess cost savings of polypectomy over a range of pregnancy rates and polypectomy costs. Pre-treatment office or operative hysteroscopic polypectomy ultimately saved €6658 ($7480) and €728 ($818), respectively, of the average cost per clinical pregnancy in women treated with four cycles of intrauterine insemination. Polypectomy prior to intrauterine insemination was cost-effective for clinical pregnancy rates greater than 30.2% for office polypectomy and 52.6% for operative polypectomy and for polypectomy price <€4414 ($4959). Office polypectomy or operative polypectomy saved €15,854 ($17,813) and €6644 ($7465), respectively, from the average cost per ongoing pregnancy for in vitro fertilization/intracytoplasmic sperm injection treated women and was cost-effective for ongoing pregnancy rates greater than 26.4% (office polypectomy) and 31.7% (operative polypectomy) and polypectomy price <€6376 ($7164). These findings suggested that office or operative hysteroscopic polypectomy was cost-effective when performed prior to both intrauterine insemination and in vitro fertilization over a range of plausible pregnancy rates and procedural costs.

Comparison of Healthcare Costs Among Commercially Insured Women in the United States Who Underwent Hysteroscopic Sterilization Versus Laparoscopic Bilateral Tubal Ligation Sterilization.

BACKGROUND: This study evaluated healthcare costs of index procedures and during a 6-month follow-up of women who had hysteroscopic sterilization (HS) versus laparoscopic bilateral tubal ligation (LBTL). MATERIALS AND METHODS: Women (18-49 years) with claims for HS and LBTL procedures were identified from the MarketScan commercial claims database (January 1, 2010, to December 31, 2012) and placed into separate cohorts. Demographics, characteristics, index procedure costs, and 6-month total healthcare costs and sterilization procedure-related costs were compared. Multivariable regression analyses were used to examine the impact of HS versus LBTL on costs. RESULTS: Among the study population, 12,031 had HS (mean age: 37.0 years) and 7286 had LBTL (mean age: 35.8 years). The majority (80.9%) who had HS underwent the procedure in a physician's office setting. Fewer women who had HS versus LBTL received the procedure in an inpatient setting (0.5% vs. 2.1%), an ambulatory surgical center setting (5.0% vs. 23.8%), or a hospital outpatient setting (13.4% vs. 71.9%). Mean total cost for the index sterilization procedure was lower for HS than for LBTL ($3964 vs. $5163, p < 0.0001). During the 6-month follow-up, total medical and prescription costs for all causes ($7093 vs. $7568, p < 0.0001) and sterilization procedure-related costs ($4971 vs. $5407, p < 0.0001) were lower for women who had HS versus LBTL. Multivariable regression results confirmed that costs were lower for women who had HS versus LBTL. CONCLUSIONS: Among commercially insured women in the United States, HS versus LBTL is associated with lower average costs for the index procedure and lower total healthcare and procedure-related costs during 6 months after the sterilization procedure.

Cost-Benefit Analysis of Hysteroscopic Polypectomy Before Controlled Ovarian Hyperstimulation and Intrauterine Insemination in Infertile Women.

Objective: To examine the cost benefit of performing hysteroscopic polypectomy (HP) in infertile women with endometrial polyp(s) before controlled ovarian hyperstimulation with intrauterine insemination (COH/IUI). Study Design: Decision analytic model comparing costs and clinical outcomes. Results: HP and COH/IUI costs ranged from $537­$12,530 and $800­$7,600, respectively. Performing an HP before COH/IUI lowered fertility cost by $7,652 per clinical pregnancy. When COH/IUI costs remained constant, HP was most cost beneficial when the cost of HP was below a threshold value of $9,452. When HP costs remained constant, the threshold value at which HP was no longer cost beneficial was at COH/IUI costs below $704. The cost benefit was greatest when an office-based HP is performed. Conclusion: HP before COH/IUI is more cost beneficial than fertility treatment alone, particularly when office-based hysteroscopy is performed.

Uterine packing versus Foley's catheter for the treatment of postpartum hemorrhage secondary to bleeding tendency in low-resource setting: A four-year observational study.

OBJECTIVE: To assess the effectiveness and safety of uterine packing versus Foley's catheter tamponade for controlling postpartum hemorrhage (PPH) secondary to bleeding tendency after vaginal delivery. METHODS: This was a prospective observational study conducted on 92 patients with primary PPH due to bleeding tendency following vaginal delivery who were unresponsive to uterotonics and bimanual compression of the uterus. Patients were divided into two groups, Uterine packing group (n = 45) and Foley catheter group (n = 47). The primary outcome was the success rate of the procedure. Secondary outcome addressed the maternal complications. RESULTS: The use of uterine packing resulted in stoppage of active bleeding in 93.3% of cases compared to only 68.1% in the Foley's catheter group (p < 0.05). Although the rate of minor complications namely fever, pain and urinary complaints were higher in the uterine packing group, it does not reach to a significant difference when compared to the Foley's catheter (p > 0.05). Six cases who failed to Foley catheter tamponade underwent emergency hysterectomy with no cases in the uterine packing group. CONCLUSIONS: The use of uterine packing to arrest PPH is simple, quick and safe procedure to avoid further surgical interventions and to preserve the fertility in low-resource setting.

High-resolution microendoscopy: a point-of-care diagnostic for cervical dysplasia in low-resource settings.

Cervical cancer is the third leading cause of cancer-related death among women in low-to-middle income countries. Pap testing and pathological services are difficult to implement under these settings. Alternative techniques for the diagnosis of cervical precancer in these settings are needed to reduce the burden of the disease. The objective of this study was to evaluate the diagnostic accuracy of a low-cost, high-resolution microendoscope imaging system in identifying precancerous lesions of the cervix in vivo. A retrospective study of 59 patients undergoing colposcopy for an abnormal Pap test was performed at Hospital de Câncer de Barretos in Brazil. All patients underwent colposcopy as per standard of care, and acetowhite lesions were recorded. High-resolution microendoscopy (HRME) images were obtained from one colposcopically normal region and from all lesions observed on colposcopy. Biopsies of abnormal areas were obtained and reviewed by three independent, blinded pathologists and compared with HRME findings. The mean nuclear area and the median nuclear eccentricity were calculated from HRME images acquired from each site. A diagnostic algorithm to distinguish histopathologically diagnosed cervical intraepithelial neoplasias of grade 2 or more severe lesions (high grade) from less severe lesions (low grade) was developed using these parameters. A test of trend was used to analyze the relationship between HRME positivity and severity of histopathogical diagnosis. Fisher's exact test was used to analyze differences in HRME positivity between high-grade and low-grade lesions. Evaluable images were obtained from 108 of 143 discrete sites. Of these, 71 sites were colposcopically normal or low grade according to histopathology and 37 were diagnosed as high grade on the basis of histopathology. Using the mean nuclear area and the median nuclear eccentricity, HRME images from 59 colposcopically abnormal sites were classified as high grade or low grade with 92% sensitivity and 77% specificity compared with histopathological findings. Increasing HRME positivity showed a significant trend with increasing severity of diagnosis (Ptrend<0.001). We found a strong association (P<0.001) between HRME positivity and a histopathological diagnosis of cervical intraepithelial neoplasia of grade 2 or higher. HRME demonstrated an accurate in-situ diagnosis of high-grade dysplasia. In low-resource settings in which colposcopy and histopathology services are severely limited or unavailable, HRME may provide a low-cost, accurate method for diagnosis of cervical precancer without the need for biopsy, allowing for a single 'screen-and-treat' approach.

Decreasing Diagnostic Hysteroscopy Performed in the Operating Room: A Quality Improvement Initiative.

OBJECTIVES: At our institution, diagnostic hysteroscopy (DH), often combined with uterine curettage, commonly has been performed in the main OR with the patient under general anaesthesia. Our objective was to create targeted interventions aimed at decreasing the number of DHs performed in the OR by 75% over one year. METHODS: This quality improvement initiative had a quasi-experimental (time-series) design. To obtain baseline numbers of DHs performed each month, we conducted a retrospective chart audit at a university teaching hospital. We implemented the following three groups of interventions: (1) staff education and case review, (2) accessible sonohysterography, and (3) an operative hysteroscopy education program. Procedures were tracked prospectively over a 12-month intervention period and an additional 12-month maintenance period. RESULTS: One hundred eleven DHs were performed at baseline. During the intervention period, 33 DHs were performed, a 70% reduction from baseline. This resulted in related savings of $126 984 and 12.5 surgical days. In the final quarter of the intervention period, there was an 81% reduction in the number of DHs with adequate preoperative evaluation compared with baseline. Twenty DHs were performed in the maintenance period, an 82% reduction from baseline. The absolute number of complications from DH remained constant during the study period. CONCLUSION: Carefully planned and targeted interventions to change the culture at our institution decreased the number of DHs performed in the main OR. These initiatives improved patient care, saved costs, and improved OR utilization. Long-term follow-up showed maintenance of the improvements in the year subsequent to the interventions.

New technologies and innovations in hysteroscopy.

Ambulatory services, with the performance of diagnostic and operative hysteroscopy as an outpatient or office procedure, are providing much of the stimulus for the development of devices that will offer women a better hysteroscopy experience. For the many women who are readily able to tolerate outpatient hysteroscopy, it offers significant advantages, as they can receive safe, efficient and effective assessment and treatment of abnormal uterine bleeding, with avoidance of the disadvantages of general anaesthesia and hospital admission. In addition, provision of such services is cost effective. Whilst the focus for the development of new devices has been the improvement of ambulatory hysteroscopy services, new instrumentation may be beneficial for hysteroscopy procedures in any setting. For ambulatory services, important goals are to reduce pain and the duration of procedures, and to enable the ready delivery of both diagnostic and therapeutic outpatient hysteroscopy. This article discusses innovations for both diagnosis and treatment. Much of the information available about these new devices has been obtained from the manufacturers or from published abstracts submitted for presentation at international meetings that have not been peer-reviewed. Some of the reported studies have been randomised controlled trials, others the results of early investigations.

Does probability guided hysteroscopy reduce costs in women investigated for postmenopausal bleeding?

OBJECTIVE: To evaluate whether a model to predict a failed endometrial biopsy in women with postmenopausal bleeding (PMB) and a thickened endometrium can reduce costs without compromising diagnostic accuracy. DESIGN, SETTING, AND POPULATION: Model based cost-minimization analysis. METHODS: A decision analytic model was designed to compare two diagnostic strategies for women with PMB: (I) attempting office endometrial biopsy and performing outpatient hysteroscopy after failed biopsy and (II) predicted probability of a failed endometrial biopsy based on patient characteristics to guide the decision for endometrial biopsy or immediate hysteroscopy. Robustness of assumptions regarding costs was evaluated in sensitivity analyses. MAIN OUTCOME MEASURES: Costs for the different strategies. RESULTS: At different cut-offs for the predicted probability of failure of an endometrial biopsy, strategy I was generally less expensive than strategy II. The costs for strategy I were always € 460; the costs for strategy II varied between € 457 and € 475. At a 65% cut-off, a possible saving of € 3 per woman could be achieved. CONCLUSIONS: Individualizing the decision to perform an endometrial biopsy or immediate hysteroscopy in women presenting with postmenopausal bleeding based on patient characteristics does not increase the efficiency of the diagnostic work-up.

Safe and cost-effective ultrasound guided removal of retained intrauterine device: our experience.

OBJECTIVES: To evaluate the efficacy and difference in cost of ultrasound guided removal of retained intrauterine device (IUD). STUDY DESIGN: A total of 23 women underwent ultrasound-guided retrieval of retained IUDs between January 2013 and March 2014. Transvaginal ultrasound was performed in all cases to assess the localization of the IUD. Under transabdominal ultrasound guidance, either the crochet type IUD hook (Gyneas, Goussainville, France) or Alligator forceps were used to grasp the IUD and remove it from the uterine cavity. The costs of the ultrasound guided procedure and the hysteroscopic removal of the IUD were compared. RESULTS: Twenty-three patients who failed IUD removal in the clinic were referred to our department for ultrasound-guided removal. All patients had an IUD present in the uterine cavity. Eleven patients had Paragard IUDs (48%), eight had Mirena IUDs (35%), three had Lippes loop (13%), and one had a ring IUD (4%). The patients' ages ranged from 20-56 years. The IUDs were in place for 8 months to 23 years. Of the 23 patients with retained IUDs, 19 were successfully removed (83%), and 4 underwent hysteroscopic removal of IUD. The IUD removal cost in the operating room on average was $3562 US dollars and the cost of ultrasound-guided removal was $465 US dollars. CONCLUSIONS: Retained intrauterine devices with or without strings can often be safely removed in an office-based setting under ultrasound guidance at less cost than in the operating room, even in cases with embedded IUDs. IMPLICATIONS: Our experience leads us to propose in-office IUD removal under ultrasound guidance as the first line in management of retained IUDs after failed removal by conventional practices. Ultrasound provides numerous advantages including direct visualization in a less invasive manner than hysteroscopy. Three-dimensional imaging can also be used for enhanced perspective.

High-resolution microendoscope for the detection of cervical neoplasia.

Cervical cancer causes 275,000 deaths each year with 85 % of these deaths occurring in the developing world. One of the primary reasons for the concentration of deaths in developing countries is a lack of effective screening methods suited for the infrastructure of these countries. In order to address this need, we have developed a high-resolution microendoscope (HRME). The HRME is a fiber-based fluorescence microscope with subcellular resolution. Using the vital stain proflavine, we are able to image cell nuclei in vivo and evaluate metrics such as nuclear-to-cytoplasmic ratio, critical to identifying precancerous epithelial regions. In this chapter, we detail the materials and methods necessary to build this system from commercially available parts.

Cost-effectiveness of office hysteroscopy for abnormal uterine bleeding.

BACKGROUND AND OBJECTIVES: Office diagnostic hysteroscopy allows physicians to directly view the endometrial cavity, tubal ostia, and endocervical canal without taking the patient to the operating room (OR). We sought to determine whether office hysteroscopy performed to evaluate abnormal uterine bleeding decreases the need for hysteroscopy performed in the OR and the associated financial and risk implications. METHODS: One hundred thirty patients who underwent office diagnostic hysteroscopy between January 2009 and March 2012 at 2 outpatient clinics in an academic university setting were identified. Records were reviewed from paper charts and electronic medical records. Hospital charts for patients who required hysteroscopy in the OR were reviewed as well. Charge estimates were obtained from our billing department. These results were analyzed for review of the data. RESULTS: Seventy-five of the 130 women who underwent diagnostic office hysteroscopy for abnormal bleeding did not need to undergo hysteroscopy in the OR. This represents estimated savings of $1498 per patient (95% confidence interval, $1051-$1923) in procedure charges. Among the 55 women who underwent OR hysteroscopy, there was 71% agreement between findings on hysteroscopy in the office and in the OR. CONCLUSION: Office hysteroscopy is a useful diagnostic tool that can help decrease the rate of diagnostic hysteroscopy in the OR under anesthesia when used in a select patient population.

Risks and benefits of hysteroscopy and endometrial sampling as a standard procedure for assessing serendipitous findings of endometrial thickening in postmenopausal women.

A retrospective study was undertaken of 35 asymptomatic postmenopausal women undergoing hysteroscopy, dilatation and curettage (H D&C) for an incidental finding of thickened endometrium to assess the rate of significant pathological findings, cost per finding and complication rate of any procedures performed. This study found one case of endometrial adenocarcinoma (1/35; 3%) at an estimated cost per significant finding of $507,116 with an estimated 11.6 complication events per finding.