Cervical lesion assessment using real-time microendoscopy image analysis in Brazil: The CLARA study.

We conducted a prospective evaluation of the diagnostic performance of high-resolution microendoscopy (HRME) to detect cervical intraepithelial neoplasia (CIN) in women with abnormal screening tests. Study participants underwent colposcopy, HRME and cervical biopsy. The prospective diagnostic performance of HRME using an automated morphologic image analysis algorithm was compared to that of colposcopy using histopathologic detection of CIN as the gold standard. To assess the potential to further improve performance of HRME image analysis, we also conducted a retrospective analysis assessing performance of a multi-task convolutional neural network to segment and classify HRME images. One thousand four hundred eighty-six subjects completed the study; 435 (29%) subjects had CIN Grade 2 or more severe (CIN2+) diagnosis. HRME with morphologic image analysis for detection of CIN Grade 3 or more severe diagnoses (CIN3+) was similarly sensitive (95.6% vs 96.2%, P = .81) and specific (56.6% vs 58.7%, P = .18) as colposcopy. HRME with morphologic image analysis for detection of CIN2+ was slightly less sensitive (91.7% vs 95.6%, P < .01) and specific (59.7% vs 63.4%, P = .02) than colposcopy. Images from 870 subjects were used to train a multi-task convolutional neural network-based algorithm and images from the remaining 616 were used to validate its performance. There were no significant differences in the sensitivity and specificity of HRME with neural network analysis vs colposcopy for detection of CIN2+ or CIN3+. Using a neural network-based algorithm, HRME has comparable sensitivity and specificity to colposcopy for detection of CIN2+. HRME could provide a low-cost, point-of-care alternative to colposcopy and biopsy in the prevention of cervical cancer.

Hysteroscopic myomectomy for submucosal type 2 fibroids with cold enucleation technique and complete fibroid extraction using a double-lumen intracervical cannula.

OBJECTIVE: To introduce a new double-lumen intracervical cannula designed to allow a single-step hysteroscopic myomectomy with nonfragmented complete fibroid extraction after cold enucleation of submucosal type 2 fibroids, avoiding complications related to the use of energy and hypo-osmolar solutions. DESIGN: Video article depicting the use of a new double-lumen intracervical cannula for single-step hysteroscopic cold myomectomy, according to our institutional care guidelines and after obtaining the patient's informed consent. (The publication of this video has been authorized by the Institutional Ethics Committee of CES University in Medellín, Colombia.) SETTING(S): Private infertility clinic. PATIENT(S): A 45-year-old woman with abnormal uterine bleeding consisting of polymenorrhea and hypermenorrhea, nonresponsive to medical treatment, caused by three type 2 (FIGO leiomyoma subclassification system) submucosal fibroids of 17, 15, and 13 mm with more than 80% of intramyometrial component. INTERVENTION(S): Hysteroscopic enucleation of three submucosal fibroids performed by blunt dissection using the 30° Bettocchi hysteroscope's bevel under continuous observation of the avascular subcapsular plane of the fibroids. Once full enucleation was attained, cervical dilatation to 12 mm with Hegar plugs was performed followed by intracervical placement of a newly designed double-lumen intracervical cannula that allows the concomitant introduction of the Bettocchi diagnostic hysteroscope and a 5-mm laparoscopic tenaculum into the uterine cavity for complete nonfragmented fibroid extraction under direct visualization. MAIN OUTCOME MEASURE(S): Complete and unfragmented fibroid extraction in a single intervention, absence of surgical complications, and postoperative course. RESULT(S): Ambulatory hysteroscopic myomectomy of three submucosal type 2 fibroids was successfully performed by blunt enucleation and complete nonfragmented fibroid extraction using the double-lumen intracervical cannula. The total operative time was 32 minutes, and the total amount of distension media (normal saline) used was 800 mL with a liquid balance of 50 mL. No surgical or anesthesia-related complications occurred. In the postsurgical evaluation, the patient classified her pain as minimal, giving it a score of 1 on a pain scale of 1 to 5 (in which 1 is the lowest and 5 the highest pain perception). When asked about the level of satisfaction with the surgical procedure, the patient reported the highest degree of satisfaction with a score of 5 on a satisfaction scale of 1 to 5 (in which 1 is the lowest and 5 the highest satisfaction). The patient reported having postsurgical regular menstrual cycles every 28 days and 3 bleeding days without hypermenorrhea. CONCLUSION(S): An efficient hysteroscopic myomectomy of submucosal type 2 fibroids with deep intramyometrial component can be performed with complete and nonfragmented fibroid extraction in a single intervention by using a newly designed double-lumen intracervical cannula. This technique allows the completion of the surgery without the need of a resectoscope, electrosurgery, or hypo-osmolar uterine distension media, thus avoiding potential complications such as thermal-induced myometrial injury and hyponatremia; a second surgical intervention will not be required because the fibroid enucleation is complete. The procedure can be performed with the use of a diagnostic hysteroscope that is widely available in gynecologic practices. (Acknowledgment: The authors thank Dr. David Olive for the invaluable help and guidance with this surgical technique and video article.).

Results of the Insertion of Hysteroscopic Sterilization Devices in a Brazilian Public Hospital.

OBJECTIVE: To evaluate the insertion of the hysteroscopic intratubal sterilization device for female sterilization concerning the technique and the feasibility. METHODS: Retrospective study with data collection of medical records of 904 patients who underwent device insertion between January and September 2016 in a public hospital in Rio de Janeiro (Brazil) with data analysis and descriptive statistics. RESULTS: In 85.8% of the cases, the uterine cavity was normal, and the most commonly-described findings upon hysteroscopy were synechiae (9.5%). The procedure lasted an average of 3.56 minutes (range: 1 to 10 minutes), and the pain was considered inexistent or mild in 58,6% of the cases, mild or moderate in 32,8%, and severe or agonizing in less than 1% (0.8%) of the cases, based on a verbal scale ranging from 0 to 10. The rate of successful insertions was of 85.0%, and successful tubal placement was achieved in 99.5% of the cases. There were no severe complications related to the procedure, but transient vasovagal reactions occurred in 5 women (0.6%). CONCLUSION: Female sterilization performed by hysteroscopy is a safe, feasible, fast, and well-tolerated procedure. The rates of successful insertions and tubal placements were high. There were few and mild adverse effects during the procedure, and there were no severe complications on the short term.

OBJETIVO: Avaliar a inserção de dispositivo intratubário de esterilização histeroscópica com relação à viabilidade e à técnica. MéTODOS: Estudo retrospectivo com coleta de dados de prontuários das pacientes submetidas à inserção do dispositivo entre janeiro e setembro de 2016 em um hospital público do Rio de Janeiro, com análise dos dados e realização de estatísticas descritivas. RESULTADOS: Foram incluídos 904 casos no estudo. Em 85,8% dos casos, a cavidade uterina estava normal, e os achados mais comumente descritos à histeroscopia foram as sinequias (9,5%). O tempo médio do procedimento foi de 3,56 minutos (gama: de 1 a 10 minutos); a dor foi considerada de ausente a leve em 58,6% dos casos, de leve a moderada em 32,8% dos casos, e de forte à pior dor possível em menos de 1% dos casos (0,8%). A taxa de inserções bem-sucedidas foi de 85,0%, e a colocação tubária foi bem-sucedida em 99,5% dos casos. Não foram identificadas complicações graves, mas reações vasovagais transitórias ocorreram em 5 mulheres (0,6%). CONCLUSãO: A esterilização feminina por histeroscopia é um procedimento seguro, viável, rápido, e bem tolerado. As taxas de inserção bem-sucedida e de colocação tubária foram altas. Houve poucos e leves efeitos colaterais durante o procedimento, e não foram observadas complicações graves no curto prazo.

Results of the insertion of hysteroscopic sterilization devices in a brazilian public hospital / Resultados da inserção de dispositivos de esterilização histeroscópica em um hospital público brasileiro

Abstract Objective To evaluate the insertion of the hysteroscopic intratubal sterilization device for female sterilization concerning the technique and the feasibility. Methods Retrospective study with data collection of medical records of 904 patients who underwent device insertion between January and September 2016 in a public hospital in Rio de Janeiro (Brazil) with data analysis and descriptive statistics. Results In 85.8% of the cases, the uterine cavity was normal, and themost commonlydescribed findings upon hysteroscopy were synechiae (9.5%). The procedure lasted an average of 3.56minutes (range: 1 to 10minutes), and the pain was considered inexistent or mild in 58,6% of the cases, mild or moderate in 32,8%, and severe or agonizing in less than 1% (0.8%) of the cases, based on a verbal scale ranging from 0 to 10. The rate of successful insertions was of 85.0%, and successful tubal placement was achieved in 99.5% of the cases. There were no severe complications related to the procedure, but transient vasovagal reactions occurred in 5 women (0.6%). Conclusion Female sterilization performed by hysteroscopy is a safe, feasible, fast, and well-tolerated procedure. The rates of successful insertions and tubal placements were high. There were few and mild adverse effects during the procedure, and there were no severe complications on the short term.

Resumo Objetivo Avaliar a inserção de dispositivo intratubário de esterilização histeroscópica com relação à viabilidade e à técnica. Métodos Estudo retrospectivo com coleta de dados de prontuários das pacientes submetidas à inserção do dispositivo entre janeiro e setembro de 2016 emumhospital público do Rio de Janeiro, comanálise dos dados e realização de estatísticas descritivas. Resultados Foram incluídos 904 casos no estudo. Em 85,8% dos casos, a cavidade uterina estava normal, e os achados mais comumente descritos à histeroscopia foram as sinequias (9,5%). O tempomédio do procedimento foi de 3,56minutos (gama: de 1 a 10 minutos); a dor foi considerada de ausente a leve em 58,6% dos casos, de leve a moderada em32,8% dos casos, e de forte à pior dor possível emmenos de 1% dos casos (0,8%). A taxa de inserções bem-sucedidas foi de 85,0%, e a colocação tubária foi bemsucedida em 99,5% dos casos. Não foram identificadas complicações graves, mas reações vasovagais transitórias ocorreram em 5 mulheres (0,6%). Conclusão A esterilização feminina por histeroscopia é um procedimento seguro, viável, rápido, e bem tolerado. As taxas de inserção bem-sucedida e de colocação tubária foram altas. Houve poucos e leves efeitos colaterais durante o procedimento, e não foram observadas complicações graves no curto prazo.

Combined Laparoscopic-Hysteroscopic Isthmoplasty Using the Rendez-vous Technique Guided Step by Step.

OBJECTIVE: To demonstrate the surgical technique of Rendez-vous isthmoplasty for the treatment of symptomatic cesarean scar defect. In this video, the authors show the complete procedure in a step-by-step manner to standardize and facilitate the comprehension and performance of the procedure in a simple and safe way. DESIGN: Step-by-step video demonstration of the surgical technique. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: The patient is a 36-year-old woman without any comorbidities, G3 C3, and with radiologic transvaginal ultrasound diagnosis of isthmocele grade 3 (over 25 mm) identified in the superior third of the cervical canal. The main steps of combined laparoscopic-hysteroscopic isthmoplasty using the Rendez-vous technique are described in detail. A combined laparoscopic-hysteroscopic approach was performed. Under general anesthesia, the patient was placed in 0° supine decubitus, with her arms alongside her body. Operative setup included 15 mm Hg pneumoperitoneum, created using the closed Veress technique, and 4 trocars: a 10-mm trocar at the umbilicus for a 0° laparoscope, a 5-mm trocar in the right iliac fossa, a 5-mm trocar in the left iliac fossa, and a 5-mm trocar in the suprapubic area. The procedure begins after a systematic exploration of the pelvic and abdominal cavities. Step 1: Identification of key anatomic landmarks and exposure of the operation field. Step 2: By carrying out blunt and sharp dissection with cold scissors or a harmonic scalpel, the visceral peritoneal layer over the isthmus area is opened, a vesicouterine space is developed, and the bladder is pushed down at least 2 cm from the lower edge of the isthmocele. Step 3: Final Phrase: By hysteroscopic exploration of the cervical canal using the vaginoscopic approach, identification and delimitation of the isthmocele its performed by recognizing the diverticular mucosal hyperplasia, and then the hysteroscopic light is pointed directly toward the cephalic limit of the scar defect. Step 4: Laparoscopic lights are decreased in intensity and the "Halloween sign" is identified (hysteroscopic transillumination). The light of the hysteroscope is pointed to the top of the cesarean scar defect allowing the laparoscopist to identify the upper and lower edges of the scar. Step 5: Laparoscopic resection of all scar tissue, excision of all the edges of the pseudo cavity. Step 6: Adequate intracorporeal suturing technique, with a 2-layer myometrial repair using intracorporeal running and interrupted stitches of polydioxanone 2-0, is done, while ensuring preservation of the cavity by not including the endometrial tissue in the myometrial suture [1-3]. Step 7: Installation of the methylene blue dye to locate any leakage. The surgery ended without any intraoperative complications and within 60 minutes. The patient was discharged on the first day postoperatively and became pregnant 6 months after surgery, with a final C-section delivery of a healthy term newborn at 39-weeks gestational age. CONCLUSION: Combined Rendez-vous isthmoplasty is feasible, safe, and effective in experienced hands, giving the surgeon a comprehensive evaluation of the anatomy of the isthmocele, and increasing the odds of a complete resection and restoration of the anatomy [4-7]. In this patient, the procedure was uneventful, without any intra- or postoperative complications, and the symptoms were completely controlled.

Esterilização tubária histeroscópica: uma atualização sobre o dispositivo Essure® / Hysteroscopic tubal sterilization: update on the Essure® device

No intuito de oferecer para a laqueadura tubária uma alternativa menos invasiva e com menos complicações, foi desenvolvido o dispositivo Essure®, aplicado ao método da esterilização histeroscópica, além de ter utilidade nos quadros de hidrossalpinge com indicação de fertilização in vitro (FIV). Este artigo, por meio de uma revisão de literatura, teve como objetivo reunir dados acerca do uso do Essure®, incluindo resultados obtidos com o dispositivo, bem como comparações em diversos aspectos com outras metodologias de esterilização. Foram utilizados os bancos de dados PubMed, Lilacs e Scielo, no período entre 1970 e 2016. Foram pesquisados os termos "hysteroscopic contraception"; "Essure"; "definitive tubal sterilization; "sterilization"; "contraception". A literatura demonstrou se tratar de um dispositivo de fácil e rápida inserção, e com bons resultados para anticoncepção. Porém, devido a complicações como perfuração tubária, implante peritoneal e aborto, bem como para avaliar seu custo financeiro ao sistema de Saúde, mais estudos prospectivos são necessários.(AU)

In order to provide a less invasive and harmful technique compared to the tubal ligation, the Essure® device was developed, applied to the hysteroscopic sterilization method. It is also used in cases of hydrosalpinus and indication of in vitro fertilization (IVF). This article, through a literature review, aimed to gather data about the use of Essure®, including results obtained with the device, comparing different aspects with other methods of sterilization. For this purpose, PubMed, Lilacs and Scielo databases were used, with results from 1970 to 2016. The keywords searched were "hysteroscopic contraception", "Essure", "definitive tubal sterilization". The literature has shown that it is a quickly and easily inserted device with good results for contraception. However, due to complications such as tubal perforation, peritoneal implantation and abortion, as well as to evaluate its financial cost to the health system, more prospective studies are needed.(AU)

Perfil das pacientes investigadas por sangramento pós-menopausa no Hospital Júlia Kubitschek nos anos de 2010 a 2014 / A survey of the profile of patients investigated for post-menopausal bleeding at Júlia Kubitschek Hospital Between 2010 and 2014

O câncer endometrial é o sexto tipo de câncer mais frequente entre as mulheres e o mais prevalente tipo de neoplasia maligna do trato genital feminino nos países desenvolvidos ocidentais. A pesquisa apresentada traz uma análise de prontuários das pacientes submetidas a procedimento diagnóstico para avaliação do endométrio entre os anos de 2010 a 2014, no no Hospital Júlia Kubitschek, para identificar em que faixa de espessamento endometrial há mais casos de câncer de endométrio e traçar um perfil das pacientes submetidas aos procedimentos de amostragem de endométrio. Os resultados sugeriram que o método diagnóstico mais utilizado para investigação foi a histeroscopia cirúrgica.

Endometrial cancer is the sixth most frequent type of cancer among women and the most prevalent type of malignancy of the female genital tract in Western developed countries. The present research brings an analysis of medical records of patients submitted to a diagnostic procedure to evaluate the endometrium between the years 2010 to 2014, in the Hospital Júlia Kubitschek, to identify in which endometrial thickening range there are more cases of endometrial cancer and to draw a profile of patients submitted to endometrial sampling procedures. The results suggested that the most used diagnostic method for investigation was surgical hysteroscopy.

Initial experience with hysteroscopic tubal occlusion (Essure®).

OBJECTIVE: To evaluate results of early tubal occlusions performed by hysteroscopy (Essure®). METHODS: This prospective study included 38 patients, 73.7% of them were white, mean age 34.5 years, they have had on average 3 pregnancies and 2.7 of deliveries. A total of 86.8% of patients previously prepared the endometrium. All procedures were carried out at outpatient unit without anesthesia. RESULTS: Insertion rate of the device was 100% at a mean time of 4 minutes and 50 seconds. Based on the analogical visual scale, average pain reported was three, and 55.3% of women did not report pain after the procedure. After 3 months, 89.5% of patients were very satisfied with the method. Simple radiographs of the pelvis showed 92.1% of topical devices, and one case of unilateral expulsion had occurred. A four years follow-up did not show failure in the method. CONCLUSIONS: Tubal occlusion through hysteroscopy at outpatient unit and without anesthesia was a quickly and well-tolerated procedure. No serious complications were seen, the success rate was high, and patients were satisfied. OBJETIVO: Avaliar os resultados das primeiras oclusões tubárias realizadas pela via histeroscópica (Essure®). MÉTODOS: Estudo prospectivo com 38 pacientes, sendo 73,7% caucasianas, com média de idade de 34,5 anos, e com 3 gestações e 2,7 partos em média. Do total, 86,8% das pacientes fizeram preparo prévio do endométrio. Todos os procedimentos foram ambulatoriais e sem anestesia. RESULTADOS: A taxa de inserção do dispositivo foi de 100%, com tempo médio de 4 minutos e 50 segundos. Segundo a Escala Visual Analógica, a dor média obtida foi de três, e 55,3% das mulheres não referiram qualquer dor após o método. Ocorreu um caso de reflexo vagal e 89,5% das pacientes retornaram às atividades normais no mesmo dia. Após 3 meses, 89,5% das pacientes encontravam-se muito satisfeitas com o método. A radiografia simples da pelve evidenciou 92,1% de dispositivos tópicos, ocorrendo um caso de expulsão unilateral. Após 4 anos de seguimento, não houve falha do método. CONCLUSÃO: A oclusão tubária por via histeroscópica em regime ambulatorial e sem anestesia foi um procedimento rápido, bem tolerado, isento de complicações graves e com alta taxa de sucesso e satisfação das pacientes.

Initial experience with hysteroscopic tubal occlusion (Essure®) / Experiência inicial com a oclusão tubária por via histeroscópica (Essure®)

ABSTRACT Objective To evaluate results of early tubal occlusions performed by hysteroscopy (Essure®). Methods This prospective study included 38 patients, 73.7% of them were white, mean age 34.5 years, they have had on average 3 pregnancies and 2.7 of deliveries. A total of 86.8% of patients previously prepared the endometrium. All procedures were carried out at outpatient unit without anesthesia. Results Insertion rate of the device was 100% at a mean time of 4 minutes and 50 seconds. Based on the analogical visual scale, average pain reported was three, and 55.3% of women did not report pain after the procedure. After 3 months, 89.5% of patients were very satisfied with the method. Simple radiographs of the pelvis showed 92.1% of topical devices, and one case of unilateral expulsion had occurred. A four years follow-up did not show failure in the method. Conclusions Tubal occlusion through hysteroscopy at outpatient unit and without anesthesia was a quickly and well-tolerated procedure. No serious complications were seen, the success rate was high, and patients were satisfied.

RESUMO Objetivo Avaliar os resultados das primeiras oclusões tubárias realizadas pela via histeroscópica (Essure®). Métodos Estudo prospectivo com 38 pacientes, sendo 73,7% caucasianas, com média de idade de 34,5 anos, e com 3 gestações e 2,7 partos em média. Do total, 86,8% das pacientes fizeram preparo prévio do endométrio. Todos os procedimentos foram ambulatoriais e sem anestesia. Resultados A taxa de inserção do dispositivo foi de 100%, com tempo médio de 4 minutos e 50 segundos. Segundo a Escala Visual Analógica, a dor média obtida foi de três, e 55,3% das mulheres não referiram qualquer dor após o método. Ocorreu um caso de reflexo vagal e 89,5% das pacientes retornaram às atividades normais no mesmo dia. Após 3 meses, 89,5% das pacientes encontravam-se muito satisfeitas com o método. A radiografia simples da pelve evidenciou 92,1% de dispositivos tópicos, ocorrendo um caso de expulsão unilateral. Após 4 anos de seguimento, não houve falha do método. Conclusão A oclusão tubária por via histeroscópica em regime ambulatorial e sem anestesia foi um procedimento rápido, bem tolerado, isento de complicações graves e com alta taxa de sucesso e satisfação das pacientes.

Formatos para preparación e informe de histeroscopia

El desarrollo de los procedimientos endoscópicos, ha hecho de la histeroscopia, un examen cada día más frecuente. En este artículo se realiza un análisis de los formatos educativos, utilizados previamente al procedimiento, los consentimientos o autorizaciones y los informes de los hallazgos encontrados. Se presentan tres modelos, con el fin de difundirlos y de unificar el informe de histeroscopia diagnóstica, en este momento en el cual, este método diagnósticom se está generalizando, permitiendo futuros análisis comparativos, entre diferentes regiones del país

Histeroscopia en el estudio preoperatorio del cáncer de endometrio / Hysteroscopy in the preoperatory study of the endometrial cancer

Se estudia con histeroscopia en forma previa a la etapificación quirúrgica a 43 pacientes que ingresaron con el diagnóstico de cáncer de endometrio al Hospital Regional de Temuco, centro de referencia regional de la novena región de la Araucanía Chile, durante 43 meses comprendidos entre 1994 y 1997 de un universo de 52 pacientes. Se compara la extensión tumoral en superficie visto en el examen histeroscópico con el grado de penetración tumoral en miometrio informado en la pieza uterina postoperatoria e informada por el anátomo patólogo. Además se evalúa el estudio histeroscópico del canal cervical en pacientes con cáncer de endometrio. Se puede evidenciar una relación significativa entre la mayor extensión del tumor en superficie y la mayor penetración miometrial. Por otra parte el estudio histeroscópico tiene una sensibilidad de un 100 por ciento y una especificidad de un 87 por ciento para evaluar el compromiso del canal cervical. Llama la atención las características epidemiológicas del grupo, en donde se observan pacientes jóvenes, multíparas y no obesas