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.

The HysNiche trial: hysteroscopic resection of uterine caesarean scar defect (niche) in patients with abnormal bleeding, a randomised controlled trial.

BACKGROUND: A caesarean section (CS) can cause a defect or disruption of the myometrium at the site of the uterine scar, called a niche. In recent years, an association between a niche and postmenstrual spotting after a CS has been demonstrated. Hysteroscopic resection of these niches is thought to reduce spotting and menstrual pain. However, there are no randomised trials assessing the effectiveness of a hysteroscopic niche resection. METHODS/DESIGN: We planned a multicentre randomised trial comparing hysteroscopic niche resection to no intervention. We study women with postmenstrual spotting after a CS and a niche with a residual myometrium of at least 3 mm during sonohysterography. After informed consent is obtained, eligible women will be randomly allocated to hysteroscopic resection of the niche or expectant management for 6 months. The primary outcome is the number of days with postmenstrual spotting during one menstrual cycle 6 months after randomisation. Secondary outcomes are menstrual characteristics, menstruation related pain and experienced discomfort due to spotting or menstrual pain, quality of life, patient satisfaction, sexual function, urological symptoms, medical consultations, medication use, complications, lost productivity and medical costs. Measurements will be performed at baseline and at 3 and 6 months after randomisation. A cost-effectiveness analysis will be performed from a societal perspective at 6 months after randomisation. DISCUSSION: This trial will provide insight in the (cost)effectiveness of hysteroscopic resection of a niche versus expectant management in women who have postmenstrual spotting and a niche with sufficient residual myometrium to perform a hysteroscopic niche resection. TRIAL REGISTRATION: Dutch Trial Register NTR3269 . Registered 1 February 2012. ZonMw Grant number 80-82305-97-12030.

[Use of hysteroscopy at the office in gynaecological practice]. / Az office hiszteroszkópia alkalmazása a nogyógyászati gyakorlatban.

INTRODUCTION: Nowadays minimally invasive techniques are a leading factors in medicine. According to this trend, hysteroscopy has been used in gynecology more and more frequently. Office hysteroscopy gives opportunity for a faster examination with less costs and strain for the patient. AIM: The aim of this work was to get familiar with the novel method. The author examined the level of pain during hysteroscopy performed for different indications with different types of instruments. In addition, the novel method invented for evaluating tubal patency was compared to the gold standard laparoscopy in 70 tubes. METHOD: Office hysteroscopy was performed in 400 cases for indications according to the traditional method. All examinations were performed in University of Debrecen, Department of Obstetrics and Gynecology in an outpatient setting. A 2.7 mm diameter optic with diagnostic or operative sheet was used. Hysteroscopies were scheduled between the 4th and 11th cycle day. For recording pain level VAS was used in 70 cases. Comparison of hysteroscopic evaluation of tubal patency to the laparoscopic method was studies in 70 cases. RESULTS: It was found that office hysteroscopy can be performed in an outpatient setting, without anesthesia. Pain level showed no difference among subgroups (nulliparous, non-nulliparous, postmenopausal, diagnostic, operative) (mean±SD, 3.5±1.01; p=0.34). For the evaluation of tubal patency, office hysteroscopy showed 92.06% accuracy when compared to laparoscopy. CONCLUSIONS: Office hysteroscopy has several advantages over traditional method. This procedure is fast, it has less strain for the patient. The novel method, rather than traditional hysteroscopy, should be used in the work-up of infertility as well.

[Results of diagnostic hysteroscopy in a 7-year period in the gynecological clinic of "UMBAL-Pleven"].

The aim of the authors is to show the data for the reception diagnosis, age, histological results and the conduct after the performed diagnostic hysteroscopies in Gynecological clinic of UMBAL-Pleven. For the fulfillment of this aim was made a prospective study for 7 years' period: from 01/01/1997 to 31/01/2003. The objects of observation were 74 women of age from 16 to 65 years, with performed hysteroscopies for gynecologic complaints. There were performed 74 diagnostic hysteroscopies for the studied period. The hysteroscopic findings were 20 cases with endometrial polyposis, 14--submucosal myoamatic nodes, deforming the uterine cavity, 4--cervical polyp, 19--increased endometrium, 9--Asherman syndrome, 1--bicomous uterus, 1--a suspected section for endometrial carcinoma and 6 cases without pathologic findings. There were performed 59 trial abrasions and the removed materials were sent for histological examination The performed comparative analysis between the hysteroscopic presentation and histological findings showed a coincidence of the diagnosis. It was made the conclusion, that the hysteroscopy is an easy, accessible and inexpensive diagnostic method, which must take its place as one of the basic contemporary diagnostic methods in gynecology.

[Hysteroscopic ablation of the endometrium in cases of dysfunctional uterine bleeding--advantage of preparations including zoladex]. / Khisteroskopska ablatsiia na endometriuma pri disfunktsionalni matochni kruvotechniia--predimstva na podgotovkata sus Zoladeks.

Hysteroscopic endometrial ablation (HEA) is a new alternative for patients with dysfunctional uterine bleeding (DUB), resistant to medical treatment. The relatively thin endometrium is a big advantage at the time of operation. In this article the results of an initial series of hysteroscopic operations (HEA) are given--as a whole and depending on preoperative treatment with GnRH-agonist. Seventeen patients with DUB underwent HEA. Six of them were pretreated with Goserelin acetate (Zoladex 3.6 mg, Astra Zeneca) two subcutaneous application at 28 days interval. The other 11 women were operated in the early postmenstrual period without medical pretreatment. Comparison was made between the two groups regarding preoperative endometrial thickness, operative time, operative complications, duration of hospital stay, change of the menstrual pattern after 6 and 12 months. Results showed 41.2% achievement of persistent amenorrhoea in patients as a whole (62.7% in the Zoladex group and 27.2% in the untreated group). Better results in the patients with Zoladex pretreatment (shorter operative time, higher incidence of amenorrhoea, patient's higher evaluation of the operation) can be explained with the reduced endometrial thickness at the time procedure. The authors consider the hysteroscopic roller-ball endometrial ablation as an upto-date cost-effective method for treatment of DUB. The method is quick, with very low incidence of complications, easy toleration, immediately recovery of the patient and the only possibility for women with high anaesthesiologic and operative risk. Two depot-doses of Zoladex before hysteroscopy lead to better intra- and postoperative results.

Relative costs of gynecologic endoscopy vs traditional surgery for treatment of abnormal uterine bleeding.

BACKGROUND: The traditional treatment for abnormal uterine bleeding when medical therapy fails has been abdominal or vaginal hysterectomy. More recently, operative gynecologic endoscopy (laparoscopy and hysteroscopy) has partially replaced this traditional approach. The cost and healthcare utilization of endoscopy compared with traditional surgical methods are poorly understood. OBJECTIVE: To compare the cost and healthcare utilization associated with different gynecologic endoscopic therapies vs traditional methods for the treatment of abnormal uterine bleeding. STUDY DESIGN: Review of the available medical literature. RESULTS: Vaginal hysterectomy is the least costly of all hysterectomy techniques. The direct costs of laparoscopically assisted vaginal hysterectomy are higher than those of abdominal hysterectomy, but the indirect costs are significantly less. The direct and indirect costs of endometrial ablation/resection are significantly lower than those of hysterectomy even when the cost of treatment failures is included. CONCLUSION: Endometrial ablation/resection might be chosen over hysterectomy to treat abnormal uterine bleeding because it avoids major surgery, significantly shortens hospitalization, and allows rapid return to normal functioning.

Advances in gynecologic care: the effect on an HMO.

The introduction of four endoscopic surgical procedures into the gynecology department at Fallon Community Health Plan (FCHP) is discussed. The use of these endoscopic procedures reduced average length of stay (ALOS), hospital days/1OOO members, and rate of postoperative complications compared to the open (laparotomy) method. These minimally invasive procedures are popular with patients and physicians, and their use has the potential to decrease an HMO's overall operational costs.

Hysteroscopy: an evolving case of minimally invasive therapy in gynaecology.

Hysteroscopy is an endoscopic technique, allowing inspection of the intrauterine cavity. Diagnostic applications of the technique began to develop in the 1970s. Although it is often claimed that diagnosis under direct visualization is better than standard dilatation and curettage, it has not yet been proved that hysteroscopic diagnosis has better results than curettage. The clinical application of therapeutic hysteroscopy, mainly in the field of the treatment of abnormal uterine bleeding, started in the 1980s. Two thousand patients have been treated with either hysteroscopic myomectomy, endometrial resection, or endometrial laser ablation, according to the literature. No randomized trials have been conducted. The first clinical results of hysteroscopic treatment seem satisfactory, with average success rates of 85%. There is some evidence that the therapy is cost saving, because hysteroscopic procedures only require one or two nights in hospital. The technique is not yet widely diffused, mainly because of technical difficulties and lack of definite evidence on its effectiveness.