Intrauterine Morcellator Devices: The Icon of Hysteroscopic Future or Merely a Marketing Image? A Systematic Review Regarding Safety, Efficacy, Advantages, and Contraindications.

The aim of this study was to analyze all available evidence regarding the use of intrauterine morcellator (IUM), for treatment of the most prevalent intrauterine benign lesions, compared to both traditional resectoscopy and conventional outpatient operative hysteroscopy in terms of safety, efficacy, contraindications, perioperative complications, operating time, and estimated learning curve. We reported data regarding a total of 1185 patients. Concerning polypectomy and myomectomy procedures, IUM systems demonstrated a better outcome in terms of operative time and fluid deficit compared to standard surgical procedures. Complication rates in the inpatient setting were as follows: 0.02% for IUM using Truclear 8.0 (Smith & Nephew Endoscopy, Andover, Massachusetts) and 0.4% for resectoscopic hysteroscopy. No complications were described using Versapoint devices. Office polipectomy reported a total complication rate of 10.1% using Versapoint device (Ethicon Women's Health and Urology, Somerville, New Jersey) and 1.6% using Truclear 5.0 (Smith & Nephew Endoscopy). The reported recurrence rate after polypectomy was 9.8% using Versapoint device and 2.6% using Truclear 8.0. Finally, the reported intraoperative and postoperative complication rate of IUM related to removal of placental remnants using Truclear 8.0 and MyoSure (Hologic, Marlborough, Massachusetts) was 12.3%. The available evidence allows us to consider IUM devices as a safe, effective, and cost-effective tool for the removal of intrauterine lesions such as polyps, myomas (type 0 and type 1), and placental remnants. Evidence regarding Truclear 5.0 suggests that it may represent the best choice for office hysteroscopy. Further studies are needed to confirm the available evidence and to validate the long-term safety of IUM in procedures for which current data are not exhaustive (placental remnants removal).

Histeroscopia de consultorio: evaluación del dolor / Office hysteroscopy: pain assessment

Objetivo: Evaluar el dolor durante la histeroscopia de consultorio, sin anestesia e investigar los factores relacionados. Métodos: Estudio prospectivo, descriptivo, analítico y de corte transversal en una población de 309 pacientes de la Maternidad “Concepción Palacios” que acudieron al Servicio de Ginecología entre agosto 2010 y agosto 2011, quienes tenían indicación para histeroscopia. Se registraron antecedentes y datos clínicos relacionados con la percepción del dolor, así como la intensidad de dolor percibida mediante una escala análoga de 0 al 10. Resultados: Se obtuvo una media de percepción de dolor de 2,9. La percepción de dolor fue leve en 56.%, dolor moderado: 36,2 %, dolor intenso: 4,9 %, dolor intolerable: 2,9 %, nada de dolor: 4,2 %. No se encontró relación entre la percepción de dolor y la edad, paridad, estado hormonal, indicación del estudio ni tipo de procedimiento. El 60,6 % de las pacientes con cuello permeable, presentaron dolor leve, mientras que las que tenían sinequias o estenosis lo presentaron en 25,5 % y 31, 3 % respectivamente. Con cuello permeable hubo 0,4 % de dolor intolerable y en presencia de sinequias la cifra fue 12,5 % (P<0,05). 88,8.% de las pacientes con dolor intolerable presentaban estenosis o sinequias. Conclusiones: La histeroscopia de consultorio es un procedimiento bien tolerado por la mayoría de las pacientes; es independiente de la paridad, condición hormonal, indicación del estudio, edad y tipo de procedimiento. La percepción de dolor fue mayor en pacientes con estenosis o sinequias cervicales.

Objective: Assess pain during no anesthesia office hysteroscopy and investigate related factors. Method: Prospective, descriptive, analytical and cross-section study in a population of 309 patients who attended the gynaecology service of Maternidad Concepción Palacios between August 2010 and August 2011, who had indication for hysteroscopy. Background and clinical data was collected, relating to the perception of pain, as well as the intensity of pain perceived by means of an analog scale of 0 to 10. Results: An average of 2.9 pain perception. The perception of pain was mild in 56 %, moderate pain: 36.2 %, severe pain: 4.9 %, intolerable pain: 2.9 %, none of pain: 4.2 per cent. No relationship was found between the perception of pain and age, parity, hormonal state, indication of the study or type of procedure. 60.6 % of patients with permeable cervix presented mild pain, while if they had adhesions or stenosis the mild pain was present in 25.5 % and 31, 3 % respectively. With permeable cervix there was 0.4 % of intolerable pain and in the presence of adhesions was only 12.5 % (P < 0,05), 88.8 % of patients with intolerable pain had cervical stenosis or adhesions. Conclusions: Office hysteroscopy is a procedure well tolerated by most patients; It is independent of parity, hormonal condition, indication of the study, age and type of procedure. The perception of pain was greater in patients with cervical stenosis or adhesions.

Accuracy of assessment of tubal patency with selective pertubation at office hysteroscopy compared with laparoscopy in infertile women.

STUDY OBJECTIVE: To estimate the accuracy of the assessment of tubal patency using selective pertubation with office hysteroscopy compared with laparoscopy in infertile women. METHOD: Selective pertubation with office hysteroscopy was also performed in 35 infertile patients prior to their scheduled laparoscopy and chromohydrotubation as part of infertility evaluation. We compared the findings of the two methods. RESULTS: Hysteroscopic tubal assessment had a 82.9% accuracy with the laparoscopic dye method taken as reference, with a positive predictive value of 87.5%, and a negative predictive value of 76.7%. No complication or failure occurred. CONCLUSION: Selective pertubation with office hysteroscopy is a useful method for the assessment of tubal patency. As a minimal invasive office procedure it can be offered as a first line method for the evaluation of the uterine cavity and the tubes in infertile women.

Comparação entre ultrassonografia transvaginal e histerossonografia na avaliação de pacientes com sangramento uterino anormal / Comparison between transvaginal ultrasonography and sonohysterography in the assessment of patients with abnormal uterine bleeding

OBJETIVO: Avaliar a eficácia da ultrassonografia transvaginal (USTV) e da histerossonografia (HSG) e compará-las na avaliação de alterações endometriais em portadoras de sangramento uterino anormal. MATERIAIS E MÉTODOS: Estudo transversal com 30 pacientes, idade entre 29 e 71 anos, 21 delas (70 por cento) na pré-menopausa e 9 (30 por cento) na pós-menopausa. Utilizou-se solução salina a 0,9 por cento para contraste na HSG. Foi considerado o achado histeroscópico e/ou histopatológico como método padrão. Utilizou-se o teste de MacNemar para comparação dos testes diagnósticos. RESULTADOS: A histeroscopia diagnosticou 18 casos (60 por cento) de alterações intracavitárias, sendo 10 pólipos (33,3 por cento). A USTV apresentou sensibilidade e especificidade de 83,3 por cento e a HSG mostrou sensibilidade de 94,4 por cento e especificidade de 91,6 por cento. O teste de MacNemar evidenciou sensibilidade (p = 0,500) e especificidade (p = 1,000) semelhantes entre a USTV e a HSG para detecção de alterações endometriais. No diagnóstico de pólipo, a HSG apresentou maior sensibilidade (90,9 por cento × 27,3 por cento; p = 0,016), com especificidade semelhante (89,5 por cento × 94,7 por cento; p = 1,000). CONCLUSÃO: A HSG e a USTV apresentam boas taxas de predição para doenças endometriais em pacientes com sangramento uterino anormal. A HSG apresenta sensibilidade e especificidade semelhantes às da USTV na detecção dessas doenças, porém apresenta sensibilidade maior para pólipos.

OBJECTIVE: To comparatively evaluate the effectiveness of transvaginal ultrasonography (TVUS) and sonohysterography (SHG) in the assessment of endometrial diseases in women with abnormal uterine bleeding. MATERIALS AND METHODS: Cross-sectional study with 30 patients, aged from 29 to 71 years, 21 (70 percent) of them premenopausal and 9 (30 percent) postmenopausal. Saline solution (at 9 percent) was utilized as contrast agent for SHG. The MacNemar test was utilized for comparison of diagnostic studies. RESULTS: Hysteroscopy diagnosed 18 cases (60 percent) of intracavitary alterations, and 10 polyps (33.3 percent). TVUS demonstrated 83.3 percent sensitivity and specificity, and SHG showed 94.4 percent sensitivity and 91.6 percent specificity. The MacNemar test showed similar sensitivity (p = 0.500) and specificity (p = 1.000) between TVUS and SHG in the detection of endometrial diseases. In the diagnosis of polyp, SHG showed the highest sensitivity (90.9 percent vs. 27.3 percent; p = 0.016) with similar specificity (89.5 percent vs. 94.7 percent; p = 1.000). CONCLUSION: SHG and TVUS present a good predictive value for endometrial diseases in patients with abnormal uterine bleeding. SHG and TVUS present similar sensitivity and specificity in the detection of such diseases, but SHG is more sensitive in the detection of polyps.

Technology assessment No. 7: Hysteroscopy.

Hysteroscopy is performed to view and treat pathology within the uterine cavity and endocervix. Diagnostic hysteroscopy allows visualization of the endocervical canal, endometrial cavity, and fallopian tube ostia. Operative hysteroscopy incorporates the use of mechanical, electrosurgical, or laser instruments to treat intracavitary pathology and perform hysteroscopic sterilization procedures. Selection of a distending medium requires consideration of the advantages, disadvantages, and risks associated with various media as well as their compatibility with electrosurgical or laser energy. A preoperative consultation allows the patient and physician to discuss the hysteroscopic procedure, weigh its inherent risks and benefits, review the patient's medical history for any comorbid conditions, and exclude pregnancy. Known pregnancy, genital tract infections, and active herpetic infection are contraindications to hysteroscopy. The most common perioperative complications associated with operative hysteroscopy are hemorrhage, uterine perforation, and cervical laceration. The procedure is minimally invasive and can be used with a high degree of safety.

Currently available devices for female sterilization.

Sterilization is now the method of family planning most commonly used in the world. Over the last 150 years, research has evolved in the search for the ideal method of female sterilization. The procedure should ideally have high efficacy, be readily accessible and be personally and culturally acceptable. The method should be simple, quick, easily learned and be able to be performed in an outpatient setting without general anesthesia. The most common and effective method for sterilization has, thus far, been via the laparoscopic route. Hysteroscopic sterilization, however, potentially fulfills many of these ideal criteria, but until recently has remained more of a concept than a reality.

Office hysteroscopy: a valuable but under-utilized technique.

PURPOSE OF REVIEW: The purpose of this review is to remind gynecologists of the indications for office hysteroscopy as well as to provide an update on equipment, techniques, and reimbursements. RECENT FINDINGS: Office hysteroscopy is a technique that has been available for over three decades. Whereas nearly 100% of urologists utilize office cystoscopy to evaluate bladder pathology, it is estimated that less than 20% of gynecologists utilize office hysteroscopy to evaluate intrauterine pathology. Although no one knows for sure, I speculate that the reasons for its under-utilization include a perceived lack of patients who would benefit from the procedure, expensive capital equipment with poor reimbursement, and a lack of expertise in performing the procedure. SUMMARY: As a result of not routinely using office hysteroscopy, many women who could greatly benefit from the use of the office hysteroscope are being denied a technique that is likely to keep them from more invasive and less useful procedures, such as diagnostic hysteroscopy and dilatation and curettage performed in the operating room under general anesthesia. This paper addresses these misconceptions in an effort to encourage more gynecologists to employ this technology.

Endometrial ablation in the year 2000--do we have more methods than indications?

Approximately 20-25% of hysterectomies are done for the relief of menorrhagia, excessive menstrual bleeding without gynecologic pathology. Menorrhagia represents a widespread clinical problem, and it is one of the leading causes of elective hysterectomy in women with a normal uterus in the US as well as in Europe. The current management of dysfunctional bleeding includes medical or different types of surgical therapies. When patients wish a nonsurgical therapy for menorrhagia we can offer them different medical treatments, a IUD releasing levonorgestrel or a therapeutic dilatation and curettage (D&C). Until recently, women who did not respond to medication were limited to either hysterectomy or continued cycles of heavy menstrual bleeding. Methods for hysteroscopic endometrial ablation were introduced in the 1980s including Nd:YAG laser ablation, transcervical resection of the endometrium (TCRE) and 'rollerball' electrocoagulation (RBE). These first-generation procedures are nowadays the gold standard for the hysteroscopic treatment of menorrhagia. In the 1990s different types of therapeutic alternatives were introduced. The second generation of hysteroscopic ablation techniques include: balloon heating methods, methods with intrauterine instillation of heated saline, the endometrial laser intrauterine thermal therapy procedure ELITT using a diode laser, global 3-D bipolar ablation method, punctual vaporizing methods, photodynamic endometrial ablation method, microwave endometrial ablation method, the radiofrequency method menostat and a cryotherapy method.

State-of-the-art flexible hysteroscopy for office gynecologic evaluation.

STUDY OBJECTIVE: To evaluate office flexible hysteroscopy without anesthesia with regard to pain, inconvenience and cost. DESIGN: A survey of patients to evaluate the level of pain they experienced during office hysteroscopy, and a comparison of costs for these procedures with those of hospital dilatation and curettage. SETTING: Office-based hysteroscopy suite in the outpatient building of a tertiary institution. PATIENTS: Women referred to this institution for gynecologic evaluation between February 1992 and December 1993. INTERVENTION: Diagnostic flexible hysteroscopy without anesthesia, cervical dilatation, or paracervical block. MEASUREMENTS AND MAIN RESULTS: A total of 417 women (mean age 42 yrs, range 16-84 yrs; 78 postmenopausal) were referred for evaluation during the study period. The most common indication for referral was abnormal uterine bleeding (86%). Hysteroscopy could not be completed in 29 women (7%), primarily because of cervical stenosis. Pain ratings obtained from 387 patients were as follows: easily acceptable discomfort, minimal discomfort during procedure, 133 (34.5%); acceptable discomfort, uncomfortable but easily bearable, 86 (22.2%); tolerable discomfort, equivalent to menstrual cramps and spasms, 106 (27.4%); barely tolerable pain, tolerable for short time only, 48 (12.4%); and intolerable pain, severe enough to stop the procedure before completion, 14 (3.6%). A single adverse event, a postprocedure temperature elevation, was easily treated with oral antibiotics. No pathology was identified in 183 (43%) of the women; 95 (22%) had polyps and 90 (21.5%) had fibroid tumors. The average duration of a procedure was 5 minutes. The charge for office hysteroscopy was $475. CONCLUSION: Flexible office hysteroscopy without anesthesia was well tolerated by the majority of the women. In addition, the procedure is far less expensive and time consuming than when it is performed in an operating room. We believe that it is a safe, well-tolerated, and cost-effective procedure of great diagnostic value.

Office hysteroscopy.

Most operative office surgery can be done easily. If, midway through a procedure in the office, the operator finds that a myoma is too large or deep to resect safely in the office, the procedure can be terminated and rescheduled for the operating room. Polyps, retained products, and the lost intrauterine device all can be treated similarly. With the proper equipment and patient selection, the well-trained hysteroscopist can do extensive operative hysteroscopy in the office. With experience, the hysteroscopist can do diagnostic and operative hysteroscopy at the same time, resulting in a substantial savings of both cost and time for the patient and the physician. The future of office hysteroscopy may include endometrial ablation and transcervical sterilization, in addition to the procedures described in this chapter. Diagnostic hysteroscopy is becoming a standard part of office gynecology. With continued training, operative hysteroscopy will move into the realm of office gynecology at the same level as diagnostic hysteroscopy.