Resectoscopic myomectomy.

OBJECTIVE: To evaluate safety and efficacy of resectoscopic myomectomy for control of menorrhagia, dysmenorrhea, and/or reproductive wastage. DESIGN: Retrospective consecutive patient follow-up. SETTING: Private practice, outpatient, hospital. PATIENTS: All patients (92) having resectoscopic myomectomy between September 1, 1986 and December 31, 1989. INTERVENTIONS: Resectoscopic myomectomy with or without concomitant procedures such as endometrial ablation. MAIN OUTCOME MEASURES: Assessment of dysmenorrhea, menorrhagia, and reproductive outcome after surgery. RESULTS: Elimination of dysmenorrhea in 24 of 28, absence of menorrhagia in 65 of 80, and pregnancy in 10 of 13 with two abortions in a total of 11 gestations. One patient was admitted and treated with one unit of autologous blood and mechanical tamponade with an intrauterine balloon. Three cases of uterine perforation had no sequelae. One patient had mild endometritis responding to outpatient antibiotics. Two cases of leiomyosarcoma were diagnosed histologically and accounted for two of the three hysterectomies noted during follow-up. CONCLUSIONS: Resectoscopic myomectomy is a safe, effective, and relatively simple outpatient surgical procedure.

Gynecologic endoscopic gas embolism.

OBJECTIVE: To alert gynecologic surgeons to the risk of room air embolism during endoscopy. DESIGN: Case reports. SETTING: Medico-legal consultations. PATIENTS: Five women having endoscopic procedures. INTERVENTIONS: Endoscopy followed by emergency resuscitative measures. RESULTS: Morbidity and mortality. CONCLUSIONS: The risk of room air embolism may be lessened by attention to the operative technique and by monitoring the end tidal carbon dioxide levels.

Treatment of the patient without intracavitary pathology. Comparison of traditional hysteroscopic techniques for endometrial ablation.

Endometrial ablation has become a necessary and useful procedure for the management of abnormal uterine bleeding in women desiring uterine conservation. Current ablation techniques are safer and more effective than earlier methods. This article explains the steps to perform laser and resectoscopic endometrial ablation and provides suggestions for making these processes more effective.

Resectoscopic myoma vaporizer.

OBJECTIVE: To evaluate a new resectoscopic electrode design intended to vaporize large intrauterine myomata. STUDY DESIGN: To study the vaporizing electrode's capabilities of destroying myomata on contact using electrical energy (cutting waveform), attempts were made to find the lowest effective power to accomplish the desired effect. Vaporization of myomata was performed in the outpatient surgical center of Cedars-Sinai Medical Center during operative hysteroscopy, with the patient under general anesthesia. The procedures were performed on 12 patients presenting with menorrhagia for whom intra-cavitary submucous myomata were discovered at office hysteroscopy, with attempts at settings of from 110-200 W. RESULTS: Vaporization of myomata readily occurred, with 200 W of pure cutting waveform current the optimal setting. CONCLUSION: A new grooved ball or grooved cylinder electrode can be used to vaporize portions of intrauterine myomata to facilitate their removal. Advantages of using the vaporizing electrode include significant reduction in the time of the procedure, avoidance of a large number of "chips" of myomata that interfere with the ease and safety of the resectoscopic procedure, apparently reduced intraoperative bleeding and intravascular intravasation.

Magnification systems alternative to the operating microscope.

PIP: This monograph chapter recommends alternatives to the costly microsurgical equipment marketed for use in gynecological surgery. 1 system, called the Corson, is a modification of a colposcope with a hand-driven zoom lens, which has a focal length of 280 mm and a range in magnification of 2.4X-24.0X. The major disadvantage of the Corson apparatus is that only the surgeon may use the scope while assistants must rely on loupes or have little participation in the procedure. Loupes, however, seem the most reasonable and cost-efficient alternative to high-cost microsurgical parapheralia. There are 2 basic loupes: 1) single-lens magnifiers and 2) multiple lens magnifiers (or actual telescopes). Single-lens systems can be made to any magnification, but there is no choice in focal length. Multiple-lens magnifiers, or surgical telescopes, allow, in addition to any desired magnification, almost any focal length. A small survey is published in this chapter of surgeons which asked how many used loupes, what brand, and what magnification. 83% used loupes. 75% used loupes at magnifications of 2.0X-4.5X. Most of the faculty members surveyed used focal lengths of 10-18 inches. Loupes were used for many gynecological procedures, but some respondents were emphatic in the instances they did not find loupes appropriate, mainly for salpingostomy, tubal reanastomosis, and tubocornual implantation, although some faculty members did use loupes for these procedures. Loupes may have other surgical indications.^ieng

The relationship of estrogen and progesterone to breast disease.

The rising incidence of breast cancer, coupled with awareness of the effects of hormones on breast tissue, has resulted in fears that estrogen, progesterone or both incite or adversely affect benign and malignant breast disease. An intensive review of the hormone physiology of the breast and of the numerous studies on hormones and breast disease reveals that estrogen and especially oral contraceptives not only do not cause breast cancer but may have a slight protective effect. Also, the overwhelming evidence is that the risk of benign breast disease is substantially reduced in both current and prior users of oral contraceptives.

PIP: The rising incidence of breast cancer, coupled with awareness of the effects of hormones on breast tissue, has resulted in fears that estrogen, progesterone, or both incite or adversely affect benign and malignant breast disease. An intensive review of the hormone physiology of the breast and of numerous studies on hormones and breast disease reveals that estrogen and especially oral contraceptives (OCs) not only do not cause breast cancer but may have a slightly protective effect. Also, the overwhelming evidence is that the risk of benign breast disease is substantially reduced in both current and prior users of OCs.

Pill formulations and their effect on lipid and carbohydrate metabolism.

PIP: Recent data on oral contraceptives (OCs) employing new low-dose formulations appear to indicate that most of the previously reported metabolic effects are minimized, particularly when a product is neigher ovverly estrogenic nor progestational. Evidence suggests that elevated levels of cholesterol and triglycerides in the plasma are correlated with the risk of cardiovascular disease. Epidemiologic students have indicated a correlation between elevation of low denisty lipoprotein (LDL) cholesterol and coronary heart disease, and a correlation between decreases in high density lipoprotein (HDL) cholesterol and arterial disease. Epidemiologic evidence seems to suggest that combination OCs are associated with increased cardiovascular risk, especially risks of venous thrombosis, myocardial infarction, and stroke. There is some debate as to whether OCs themselves are an independent risk factor or whether they increase the effects of other risk factors. Women using combination OCs have been reported to have higher total serum triglyceride and cholesterol concentrations, related primarily to the estrogen dose. While most of the earlier literature associated estrogens with a higher risk of cardiovascular disease, recent studies have increasingly implicated the progestin component. Increasing potencies of progestin have been found to proportionally lower the HDL-cholesterol level. There is a positive association between the estrogen dose and HDL-cholesterol level. Among combination pill users, HDL levels gevverally depend on the relative amounts and potencies of both components. It is generally agreed that there are some high-risk women who should be carefully monitored while using the pill or who should not use it at all. Steroid type and dosage both play a role in affecting carbohydrate metabolism. Ethinyl estradiol (EE), the estrogen component in most OCs, does not seem to have the same biphasic effect on carbohydrate metaolism as most other estrogens. Most of the recent literature suggests that 19-norprogestins alter carbohydrate metabolism in a dose-related manner. The major problems in carbohydrate metabolism have been caused by high dose OCs and the progestin norgestrel. The recent literature confirms the advantages of the new low-dose compounds, with 1 study finding no adverse effects on carbohydrate metabolism and no significant change in plasma insulin levels with a dose of 35 mcg EE and .4-.5 mg norethindrone. The use of OCs in prediabetic and insulin-dependent diabetic women must be weighed against the dangers of pregnancy and the characteristics of the individual patients.^ieng

Preoperative therapy in preparation for endometrial ablation.

In order to improve the success of endometrial ablation for uncontrolled uterine bleeding, a variety of preoperative agents were utilized. Patients were given either no preparation, progestins, danazol or leuprolide acetate depot as preoperative therapy to determine the best way to increase the incidence of amenorrhea and to decrease the failure rates. The lowest rates were achieved with danazol or no preparation, with amenorrhea rates of 41 and 43%, respectively. The highest rates were obtained with the use of either progestins or leuprolide acetate depot, 61 and 67%, respectively. Progestin use was discontinued early in the study because of side effects, resulting in numbers too low for accurate comparison. We concluded that the use of leuprolide acetate depot in a single-dose regimen resulted in the highest amenorrhea rates, with minimal or no side effects.

Endometrial ablation in women with abnormal uterine bleeding aged fifty and over.

Endometrial ablation, rapidly becoming a standard operation for the management of abnormal uterine bleeding, is usually performed for patients between ages 35 and 45. This study reports on the results of resectoscopic endometrial ablation for 26 patients aged 50 and older, followed from 7 to 43 months (average follow-up period, 21 months). Seventeen of the patients were menopausal at the time of the procedure or became menopausal during the follow-up period, with 13 on combined estrogen and progestin therapy and 4 on unopposed estrogen (because of progestin intolerance). Twenty-three of the 26 patients (88%) are amenorrheic, one premenopausal patient has normal periods and none have failed. The fear of hiding glandular tissue that subsequently becomes malignant is discussed and believed to be highly unlikely to occur.

Abdominal wall hot spots in pregnant women.

Using a hand-held infrared temperature sensor, temperatures were recorded from the abdominal wall in antenatal patients at 35+ weeks' gestation. The inguinal and periumbilical areas appeared to be relative "hot spots" in normal pregnancy. This noninvasive technique may be useful in confirming the diagnosis of chorioamnionitis.

Preparation of the endometrium for ablation with a single dose of leuprolide acetate depot.

Several reports describe enhancing the efficacy of laser or resectoscopic endometrial ablation procedures by preparing the endometrium with danazol or progestin therapy. Because gonadotropin releasing hormone agonists have been found to inhibit the thickness and development of the endometrial lining, preparation of the endometrium for resectoscopic ablation was attempted on eight women using a single injection of 7.5 mg of leuprolide acetate depot. When the ablation was performed, one month after the injection of the medication, which had occurred on day 20-24 of the prior menstrual cycle, the endometrium was thinned in all the patients, with inactive glands, reduced vascularity and atrophic stroma.

Treatment of abnormal uterine bleeding with the gynecologic resectoscope.

The gynecologic resectoscope, recently approved by the Food and Drug Administration for the treatment of abnormal uterine bleeding, was evaluated for its success in the treatment of women with this complaint. Through June 1990, 216 patients were treated with this modality. Ninety were treated with transcervical myomectomy alone since they still desired fertility preservation or wished to avoid hysterectomy. Of the patients treated, 189 (87.5%) had follow-up evaluation for at least three months and some as long as three years. Of the ninety patients treated with resection of a submucous myoma, greater than 90% had a marked improvement in their symptoms, with decreased menstrual bleeding. Of the 96 patients treated with endometrial ablation, 50% were amenorrheic, 26% had hypomenorrhea, 17% had eumenorrhea, and 7% were unimproved. There was only one case of fluid overload, and no patients required a blood transfusion. Complications included two cases of endometritis and one perforation at the time of retrieval of myoma fragments. Four patients required placement of a 30-mL Foley catheter for control of postoperative bleeding. Gynecologic resectoscopy is a safe and effective alternative to major surgery in the management of abnormal uterine bleeding for which conservative measures have not been effective.

Experience with the Hamou colpomicrohysteroscope.

The Hamou colpomicrohysteroscope has a narrow diameter that permits its use in an office setting without anesthesia or analgesia. This instrument's magnification capability, up to 150X, gives it extreme versatility such that it can be used as a panoramic hysteroscope or as a contact colpomicroscope. This report details the early experience with this instrument in two gynecologic practices.

TV laparoscopy. A new dimension in visualization and documentation of pelvic pathology.

A new miniature color TV camera is employed routinely during laparoscopy. It offers the following advantages: a binocular view from a convenient distance; a significantly enlarged image; easy observation of minute changes; observation of the procedure by the entire team, thereby permitting faster coordinated manipulations involving the assistant; provision of simultaneous, permanent records; and the method of choice in teaching.

Removal of cornual polyps with flexible hysteroscopy and a wire basket. A case report.

The hysteroscopic removal of large uterine polyps often can assist infertile women in conceiving. This report describes the removal of bilateral cornual polyps in a diethylstilbestrol-deformed, T-shaped uterus using a flexible operating hysteroscope and an 0.8-mm ureteral wire stone basket.

Hysterectomy vs. resectoscopic endometrial ablation for the control of abnormal uterine bleeding. A cost-comparative study.

This study compared the costs of endometrial ablation using the uterine resectoscope to those of hysterectomy in a group of patients treated for abnormal uterine bleeding who were enrolled in a national managed health care organization. The cost of endometrial ablation during the periprocedural period was significantly lower than that of hysterectomy, with much of the difference coming from the hospitalization required for the latter procedure. The postprocedural cost for ablation was higher than for hysterectomy owing to the need for second ablations or hysterectomy in 13 of the 85 ablation patients. Preprocedure costs were not different between ablation and hysterectomy. A reanalysis of the data, however, that excluded patients who required a second ablation or hysterectomy suggested that these additional procedures were responsible for the higher postprocedural costs in the ablation group. Resectoscopic endometrial ablation for the treatment of abnormal uterine bleeding resulted in lower periprocedure costs and lower overall treatment costs to the health plan in the groups studied as compared with hysterectomy. Greater familiarity with the technique of resectoscopic endometrial ablation, improved patient selection for the procedure and the use of appropriate pharmacotherapy for suppressing endometrial growth prior to ablation probably substantially improve the rate of success, reduce postprocedural costs and further enhance the cost advantage of this procedure.

Resectoscopic removal of symptomatic intrauterine lesions.

In order to avoid major surgical intervention in women who refused or were poor risks for hysterectomy or myomectomy, a hysteroscopic resectoscope was used for 90 women with uncontrollable uterine bleeding due to submucous fibroids or large polyps or with menorrhagia with normal endometria. Of those patients followed for more than three months, 90% of endometrial ablation patients had an improvement in menstrual flow, with 79% having scant or no periods. For patients with submucous fibroids or polyps, 91% had resumption of normal menses. For the 15 patients who were infertile and underwent submucous fibroid or polyp resection the term pregnancy rate is 33% to date. With only two complications in the series (perforation and endometritis), the conclusion is that resection of submucous lesions and endometrial ablation using the resectoscope is a safe and highly effective alternative to hysterectomy for those conditions.

Effects of vasopressin administration during hysteroscopic surgery.

A study was performed to assess the effect of dilute vasopressin on intraoperative bleeding and intravasation of the medium during resectoscopic hysteroscopic surgery. Dilute vasopressin or placebo was injected into the cervical stroma at the commencement of resectoscopic endometrial ablation and/or submucous myomectomy in a prospective, computer-generated, double-blind, placebo study. The operator estimated the intraoperative bleeding. The inflow volume and outflow recovered volume of sorbitol, used as a distending medium, were recorded. Pressures were kept constant with a pump. Operating time was also recorded. In 64 women the mean inflow volume was 5,584 mL (range, 500-27,000), and the mean deficit (intravasation) was 311 mL (range, 0-2,100). The mean surgical time was 37.1 minutes (range, 11-120). The deficit volume was related to the duration of surgery (P = .001) and to total inflow volume (P = .001). Increased operating time and volume infused also increase intravasation. Multivariate analysis showed that patients receiving vasopressin had a 0.36 risk of intravasation (confidence limit, 0.14-0.91) as compared with the placebo. Vasopressin injected intracervically, in conjunction with resectoscopic intrauterine surgery, reduces but does not eliminate intravasation of the medium. It also decreases intraoperative bleeding.

The importance of instrumentation and documentation in gynecological laparoscopy.

PIP: It is estimated that approximately 10,000 gynecological laparoscopies have been performed each year for the last 2 years and the number is increasing. This is a report on the evaluation of 14 separate endoscopic instruments. To produce pneumoperitoneum, air has been replaced by carbon dioxide gas or nitrous oxygen. The Semm insufflator measures the intra-abdominal pressure and indicates when the inflow of gas meets resistance. This aids in determining the proper position of the needle. The clinical impression is that intra-abdominal pressure in the vicinity of 25 mm Hg rather than 16 mm is most important. The Veress pneumo-needle with the spring-loaded stylet helps avoid injury to viscera. The trocar is the most dangerous tool. The smallest (7 mm) diameter with the shortest sharp tip is recommended. The first optical system (invented in 1875) has been replaced by the "rod-lens" system, which increases light transmission, gives a brighter image, has a wider viewing angle, and has a smaller outside diameter of the telescope. Use of a second trocar is safer because introduction is observed under visual control. The punch-type of biopsy forceps provides a smooth sharp cut dividing the tubes after coagulation and transects a 3 mm sample for microscopic examination. Another smaller trocar may be needed to pass through a grasping forceps to hold the ovary in position if a biopsy of the ovary is needed. The coagulation-suction probe may be used if hemorrhage obscures the operating field. Burn accidents may occur unless half to 1 inch of the insulated part of the instrument protrudes beyond the metal trocar. Solid-state electro-surgical units are recommended over the old spark-gap-generation type. Proper inspection of all electrical equipment before use is needed to prevent burns. After appropriate cleaning and drying of instruments, gas sterilization is recommended. The single puncture approach is not recommended as two trocars are more efficient. Under investigation are: documentation of findings by compact 35 mm cameras or 16 mm movies, more safe illumination without large trocars, less heat production from light source, and special light-weight cameras. Adequte physician training and experience is the most important factor. The best instruments cannot substitute for thorough training.^ieng