Diagnostic and therapeutic advantages of hysteroscopic surgery in management of intrauterine lesions in postmenopausal women.

STUDY OBJECTIVE: To determine the value of hysteroscopic surgery in the management of intrauterine lesions in postmenopausal women. DESIGN: Descriptive study (Canadian Task Force classification II-2). SETTING: Tertiary care university hospital. Patients. Fifty postmenopausal women, most with vaginal bleeding, all with intrauterine lesions (leiomyomas, polyps, adhesions) on hysteroscopy or ultrasound. INTERVENTION: Hysteroscopic operations consisting of myomectomy, polypectomy, and adhesiolysis. MEASUREMENTS AND MAIN RESULTS: Forty-seven procedures were completed successfully by hysteroscopy; partial myomectomies were performed in three women for large or deeply embedded leiomyomas. The only complication was one case of fluid overload. Median operating time was 20.0 minutes (range 5.0-60.0 min) and median postoperative hospital stay was zero days (range 0-2 days). Eight patients (16%) subsequently underwent hysterectomy, mostly for uterine malignancy or premalignancy. In two cases, the operative specimen included malignant elements that were not evident on preoperative endometrial biopsy. During mean follow-up of 33.1 months (range 6-72 mo), 95.2% of women without hysterectomy were free of symptoms. CONCLUSION: Hysteroscopic surgery is an effective and safe option for postmenopausal women with intrauterine lesions. It allows the correct diagnosis to be made, reduces the need for major and unnecessary surgery, and is therapeutic in most patients. (J Am Assoc Gynecol Laparosc 8(1):87-91, 2001)

Laparoscopic 'oophorectomy-in-a bag'--an alternative to laparotomy for the evaluation of suspicious ovarian masses.

A prospective observational study was performed to assess the feasibility of the technique of laparoscopic 'oophorectomy-ina bag' for the safe removal of ovarian masses that do not meet the standard guidelines for laparoscopic management of adnexal pathology. Ovarian lesions were selected preoperatively by: age of the patient, ultrasound appearance, bilaterality and size. None of the women had ascites or matted bowel on ultrasound, and all had normal serum tumour markers. There were no stigmata of malignant disease in any of the cases at the time of surgery. Twenty women were recruited. Eighteen procedures (90.0%) were completed successfully laparoscopically. In two cases the bag could not be removed laparoscopically and minilaparotomy was performed. Nineteen of the tumours (95.0%) were removed without intra-abdominal spillage; the bag ruptured in one case. There were no major complications. One case of borderline ovarian tumour (stage Ia) was discovered. We conclude that laparoscopic 'oophorectomy-in-a bag' allows for the safe removal of suspicious ovarian tumours. The advantages of this approach are that women can be treated locally, a laparotomy is avoided, and the subgroup with ovarian malignancy can be identified to be referred to an oncological centre.

A case-control study to compare the variability of operating time in laparoscopic and open surgery.

The purpose of this study was to compare the variability of operating times for some of the most common gynaecological procedures performed laparoscopically and by open surgery. The case notes of 60 women randomly selected from a cohort of 600 who had undergone laparoscopic surgery for ectopic pregnancy, ovarian cysts, leiomyoma and hysterectomy were reviewed. These patients were matched with an equal number of women who had been treated by open surgery for similar indications. Additional matching criteria included age (+/-2 years), size of the lesion in cases of ovarian cysts and fibroids (+/-3 cm), the period of amenorrhoea in ectopic pregnancies, and uterine size and pelvic pathology in women undergoing hysterectomy. Comparison of laparoscopy and laparotomy showed that the mean procedure times were similar for the two routes of surgery, with the exception of hysterectomy which took significantly longer if done laparoscopically. The duration of laparoscopic surgery for ectopic pregnancy, ovarian cystectomy and hysterectomy was significantly less predictable than at laparotomy. These data indicate that with the exception of hysterectomy, the average operating time for laparoscopic procedures is comparable to that for laparotomy. In contrast, the variability of duration of laparoscopic surgery tends to be much greater than with laparotomy for all procedures considered.

How long does laparoscopic surgery really take? Lessons learned from 1000 operative laparoscopies.

The purpose of this study was to assess the operating time of the most common gynaecological laparoscopic procedures. We analysed retrospectively 1000 consecutive operative laparoscopies on a procedure-by-procedure basis. Diagnostic laparoscopy and laparoscopic sterilization were specifically excluded from the analysis. The various laparoscopic procedures were grouped and analysed under six major categories. The average operating time for all cases was 76.9 min (range 10-400). In 38 cases (3.8%) the laparoscopic procedure was converted to laparotomy. The average operating time for treating ectopic pregnancy and tubal disease was approximately 60 min (range 13-240). Surgery for endometriosis and ovarian cysts averaged 72 min (range 10-240). Laparoscopic myomectomy and hysterectomy averaged 113 and 131 min respectively (range 25-400). Our results show that while the operating time for most operative laparoscopies is less than 75 min, the range of operating times is great. The relative lack of predictability in procedure times means that the efficient utilization of fixed theatre sessions is difficult.

The excision of uterine fibroids by vaginal myomectomy: a prospective study.

OBJECTIVE: To evaluate the clinical effectiveness and safety of the excision of uterine fibroids by vaginal myomectomy. DESIGN: Prospective study. SETTING: A gynecology department of a university teaching hospital. PATIENT(S): Women with menorrhagia, pelvic pain, symptoms of pressure, or subfertility attributable to moderate-sized uterine fibroids who otherwise would have required abdominal or laparoscopic myomectomy. INTERVENTION(S): Vaginal myomectomy. MAIN OUTCOME MEASURE(S): The feasibility of vaginal surgery, operative complications, postoperative recovery, and relief of symptoms. RESULT(S): Myomectomy was completed vaginally in 32 (91.4%) of 35 patients and none required hysterectomy. The overall operating time was 78 minutes, the estimated operative blood loss was 313 mL, and the mean postoperative hospital stay was 4 days. Pelvic hematomas developed in 4 patients, and one colpotomy required resuture. Seventy-four percent of the women reported relief of their symptoms at 3 months' follow-up. Three patients have had full-term pregnancies since the operation. CONCLUSION(S): Myomectomy can be performed by the vaginal route in selected cases with low morbidity and a good short-term success rate. Unlike open myomectomy, it requires no skin incision, and unlike laparoscopic myomectomy, it can be used in patients who have numerous, relatively large, and intramural fibroids.

A simple technique of securing inferior epigastric vessels and repairing the rectus sheath at laparoscopic surgery.

Trauma to the inferior epigastric artery during insertion of ports for laparoscopic surgery can be associated with major hemorrhage. Several techniques have been developed to deal with this emergency, but most require special and expensive instrumentation that may not be readily available. We describe a simple and quick method to deal with this complication using only standard sutures and a laparoscopic needle holder. Two sutures with straight needles are inserted below laterally and medially to the vessels and pulled out via a contralateral port. The sutures are tied together and pulled back into the abdominal cavity and tied to secure the vessels. The procedure is repeated above the vessels to produce complete hemostasis. The technique also can be applied easily to repair the rectus sheath after using large trocars and cannulas and thereby prevent herniation.

Randomised placebo controlled trial of mefenamic acid for premedication at outpatient hysteroscopy: a pilot study.

An increasing number of diagnostic hysteroscopies are being performed in an outpatient setting. Most women tolerate the examination well, but the single commonest reason for failure is pain. We assessed the efficacy of a nonsteroidal, anti-inflammatory analgesic as premedication before hysteroscopy in a double-blind, placebo controlled trial. Our results showed that 500 mg mefenamic acid given one hour before hysteroscopy had no significant benefit in the discomfort experienced during the procedure but did significantly reduce pain after hysteroscopy. A larger dose or a longer interval between premedication and hysteroscopy may possibly be associated with greater benefits.

Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial.

OBJECTIVE: To assess the efficacy of lignocaine spray during outpatient hysteroscopy in reducing the need for additional anesthesia and reducing the discomfort of the procedure. DESIGN: A randomized double-blind, placebo-controlled trial. SETTING: An undergraduate university teaching hospital in London. PATIENT(S): One hundred twenty patients undergoing outpatient hysteroscopy. INTERVENTION(S): Application of lignocaine spray to the cervix, cervical canal, and uterine cavity during outpatient hysteroscopy. MAIN OUTCOME MEASURE(S): The need to use additional anesthesia and the pain experienced at various steps of the procedure. RESULT(S): Women treated with active spray experienced significantly less pain when the cervix was grasped with a tenaculum at the start of hysteroscopy. There were no other significant differences in the outcome of hysteroscopy between the placebo and lignocaine groups, although there was a significant reduction in the use of additional anesthesia in both groups compared with historical controls. CONCLUSION(S): Lignocaine spray has beneficial effects on cervical but not uterine sensation. Pretreatment with either lignocaine or placebo seems to reduce the need for additional intracervical anesthesia during hysteroscopy.

Monitoring fluid absorption using 1% ethanol-tagged glycine during operative hysteroscopy.

STUDY OBJECTIVE: To assess the value of expired breath ethanol as a marker of irrigating fluid absorption during hysteroscopic surgery using 1% ethanol-tagged 1.5% glycine. DESIGN: Prospective analysis. SETTING: Endoscopy training center of a university hospital. PATIENTS: Forty-eight women undergoing major hysteroscopic surgery for menorrhagia (40 transcervical endometrial resections, 8 rollerball endometrial ablations). INTERVENTIONS: Expired breath ethanol and venous blood samples were taken before and at 10-minute intervals during surgery. Volumetric absorption of irrigating fluid was checked at the same time. MEASUREMENTS AND MAIN RESULTS: Expired breath ethanol concentration, serum ethanol, several biochemical variables, and volume of absorbed irrigating fluid (direct and indirect) were measured. There was a linear positive correlation (r = 0.86, p <0.001) between direct vascular absorption of the irrigating fluid and expired breath ethanol concentration. Prediction can be given with 95% confidence that if the alcolmeter reading is below 0.45%, the volume of irrigating fluid absorbed is below 2000 ml. No significant correlation was seen between expired breath ethanol and indirect fluid absorption. CONCLUSIONS: As it is not possible to distinguish direct and indirect fluid absorption during hysteroscopic surgery, measuring expired breath ethanol is insufficient to assess overall fluid balance, and continuous volumetric assessment is still required.

Indications and alternatives to hysterectomy.

Hysterectomy is the commonest major operation performed by gynaecologists and is the definitive cure for many of it's indications which include dysfunctional uterine bleeding, fibroids, utero-vaginal prolapse, endometriosis and adenomyosis, pelvic inflammatory disease, pelvic pain, gynaecological cancers and obstetric complications. It is a successful operation in terms of relieving women of their presenting symptoms and high levels of satisfaction are reported by patients. However, it has a high risk of complications, involves a prolonged convalescence, is expensive and to some women represents a loss of femininity. It should only be employed after trying conservative treatments first if appropriate. If this fails, currently only endometrial ablation and myomectomy are valid alternatives to hysterectomy. If ultimately hysterectomy is required, there is considerable evidence that patient care can be improved by increasing the proportion of operations that are done vaginally and laparoscopically and decreasing the number of laparotomies.

Does endometrial resection help dysmenorrhea?

BACKGROUND: Menorrhagia is a common symptom and is often associated with dysmenorrhea. METHODS: The effect of transcervical resection of the endometrium (TCRE) on dysmenorrhea associated with menorrhagia was investigated in a prospective study. Ninety consecutive women were monitored before surgery and for a period of up to 12 months after resection. The amount of pelvic pain experienced was scored daily on a scale of 0-3, and was timed in relation to menstruation. RESULTS: There was a significant decrease in the level of pain experienced during menstruation and overall during the menstrual cycle (p < 0.001), but not in the premenstruum. The effect on pain was immediate and was maintained throughout the follow-up period of the study. The presence of adenomyosis or leiomyomata in the surgical specimen did not influence the beneficial effect on pain. CONCLUSIONS: Based on these findings, dysmenorrhea during menstruation should not be a contraindication to transcervical endometrial resection in women with menorrhagia.

Medical Research Council randomised trial of endometrial resection versus hysterectomy in management of menorrhagia.

BACKGROUND: The most frequent indication for hysterectomy is menorrhagia, even though the uterus is normal in a large number of patients. Transcervical resection of the endometrium (TCRE) is a less drastic alternative, but success rates have varied and menorrhagia can recur. We have tested the hypothesis that the difference in the proportion of women dissatisfied and requiring further surgery within 3 years of TCRE or hysterectomy would be no more than 15%. METHODS: 202 women with symptomatic menorrhagia were recruited to a multicentre, randomised, controlled trial to compare the two interventions. TCRE and hysterectomy were randomly assigned in a ratio of two to one. The primary endpoints were women's satisfaction and need for further surgery. The patients' psychological and social states were monitored before surgery, then annually with a questionnaire. Analysis was by intention to treat. FINDINGS: Data were available for 172 women (56 hysterectomy, 116 TCRE); 26 withdrew before surgery and four were lost to follow-up. Satisfaction scores were higher for hysterectomy than for TCRE throughout follow-up (median 2 years), but the differences were not significant (at 3 years 27 [96%] of 28 in hysterectomy group vs 46 [85%] of 54 in TCRE group were satisfied; p = 0.16). 25 (22%) women in the TCRE group and five (9%) in the hysterectomy group required further surgery (relative risk 0.46 [95% CI 0.2-1.1], p = 0.053). TCRE had the benefits of shorter operating time, fewer complications, and faster rates of recovery. INTERPRETATION: TCRE is an acceptable alternative to hysterectomy in the treatment of menorrhagia for many women with no other serious disorders.

Combined ultrasonographically guided drainage and laparoscopic excision of a large ovarian cyst.

Large ovarian cysts are conventionally treated by laparotomy. We describe a technique of transabdominal drainage under ultrasonographic control followed by laparoscopic excision of an ovarian cyst that was 24 x 10 x 20 cm. This approach has the benefits of minimal-access surgery and is suitable for unilocular benign cysts of any size.

A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy.

OBJECTIVE: To assess the feasibility and safety of vaginal removal of ovaries at the time of vaginal hysterectomy. DESIGN: Prospective study. SETTING: London teaching hospital. POPULATION: Between March 1993 and March 1995, 40 women were admitted under the care of one consultant for vaginal hysterectomy and bilateral oophorectomy. METHODS: The success rate of removing the ovaries vaginally was calculated and the operative time, blood loss, intra- and post-operative complications and patient recovery were analysed and compared with 48 patients who had a vaginal hysterectomy but retained their ovaries during the same time period. RESULTS: Thirty-nine (97.5%) of the 40 women due to undergo removal of the ovaries were managed successfully via the vaginal route; one woman required laparoscopic removal of one of her ovaries containing an ovarian cyst which was not diagnosed pre-operatively. A variety of techniques were used for vaginal oophorectomy which included salpingo-oophorectomy, oophorectomy without salpingectomy, and transvaginal endoscopic oophorectomy utilising endoloop sutures or bipolar electrosurgery. Oophorectomy added a mean of 23.4 min (88.3 vs 64.9 min, 95% CI 10.2-36.7, P < 0.001) to the total operating time compared with vaginal hysterectomy alone. No laparotomies were required, and both the complication rate and post-operative inpatient stay were similar for the two groups. CONCLUSIONS: The need to perform oophorectomy should not be considered a contraindication to vaginal hysterectomy.

Randomized studies in endoscopic surgery--where is the proof?

We have attempted to review the best available evidence for the commonest gynaecological endoscopic procedures. Controlled studies are the exception rather than the rule, and randomized studies are even rarer. Therefore, the results of large, uncontrolled series must be acknowledged. As a result, for most procedures, sufficient information is now available regarding indications, efficacy, and complications to determine their role in routine clinical practice.

Hysteroscopy in women with abnormal uterine bleeding on hormone replacement therapy: a comparison with postmenopausal bleeding.

OBJECTIVE: To determine the role of outpatient diagnostic hysteroscopy in patients with abnormal uterine bleeding (AUB) on hormone replacement therapy (HRT) and to contrast this with a control group of women presenting with postmenopausal bleeding. DESIGN: Comparative observational study. SETTING: Outpatient hysteroscopy clinic in a university hospital. PATIENTS: Three hundred ten patients undergoing outpatient hysteroscopy. INTERVENTIONS: Outpatient diagnostic hysteroscopy with endometrial biopsy when indicated. MAIN OUTCOME MEASURES: Hysteroscopic findings, need for cervical dilatation and local anaesthesia, correlation between hysteroscopy and histologic diagnosis. RESULTS: There were 157 (7.1%) patients with AUB on HRT and another 153 (6.9%) with postmenopausal bleeding out of 2,203 outpatient hysteroscopies. Hysteroscopy was successful in 97% and 92% of patients, respectively, and intrauterine pathology was diagnosed in 46.7% and 39.7% of these cases. Functional endometrium was noted significantly more often with HRT and endometrial atrophy with postmenopausal bleeding. Overall, local anesthesia was used in 126 (40.6%) and shown to be associated significantly with the need for cervical dilatation. Endometrial biopsy was attempted in 125 (80%) and 119 (78%) patients in the study and control groups, but was unsuccessful significantly more often with postmenopausal bleeding (38.7%) versus 16%). There were six cases of endometrial carcinoma, all in the control group. CONCLUSION: There is a high incidence of intrauterine abnormalities in women with menstrual symptoms while taking HRT, but the pathology differed from those with postmenopausal bleeding. As focal lesions are found commonly in such patients, their detection by diagnostic hysteroscopy should improve compliance with HRT as it would allow individualization of treatment.