Hysteroscopic Access and Uterine Cavity Evaluation 12 Months after Endometrial Ablation with the Cerene Cryotherapy Device.

STUDY OBJECTIVE: To evaluate whether physical access and the ability to systematically assess the postablation uterine cavity were preserved at 12 months after endometrial ablation with the Cerene cryotherapy device (ChannelMedsystems, Emeryville, CA). DESIGN: A prospective, multicenter, single-arm study. SETTING: In the clinic at 8 US sites and outpatient hospital setting at 2 sites in Canada and 1 site in Mexico. PATIENTS: A total of 230 (of 242) subjects continued in the study at the Month 12 visit after ablation. Two hundred twenty-three subjects were available for a diagnostic hysteroscopic evaluation. INTERVENTIONS: Subjects who had previously been treated with a 2.5-minute cryoablation of the endometrium utilizing the Cerene device underwent a diagnostic hysteroscopy at the Month 12 follow-up visit. MEASUREMENTS AND MAIN RESULTS: The uterine cavity was accessible in 220 of 223 subjects (98.7%) and not accessible in 3 (1.3%) because of pain (n = 2) and cervical stenosis (n = 1). Visualization of the uterine cavity was possible in 204 of 220 subjects (92.7%) with one or both tubal ostia identified in 89.2% (182 of 204) of subjects. Both tubal ostia were visible in 160 of 204 subjects (78.4%) and one ostium in 22 of 204 subjects (10.8%). The cavity was not visualized in the remaining 16 of 220 subjects (7.2%) because of intrauterine adhesions (n = 14), technical difficulties (n = 1), or menstruation (n = 1). In 95.6% (195 of 204) of subjects where the cavity was visualized, the hysteroscopic view was judged adequate to evaluate the uterine cavity for pathologic change. No significant complications occurred during the hysteroscopic evaluations. CONCLUSION: This is the largest study to date conducted to hysteroscopically evaluate the postablation uterine cavity. Uterine cavity assessment with in-office hysteroscopy 1 year after the use of the Cerene cryotherapy device is attainable, enabling both diagnostic and therapeutic procedures within the endometrial cavity.

Surgical and Reproductive Outcomes after Hysteroscopic Removal of Retained Products of Conception: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the impact of hysteroscopy for retained products of conception (RPOC) removal on surgical and reproductive outcomes. DATA SOURCES: Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, SciELO, EMBASE, and the Cochrane Central Register of Controlled Trials at the Cochrane Library) were searched from inception to March 2020. METHODS OF STUDY SELECTION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Medical Subject Headings terms and text words such as "retained products of conception," "placental remnants," "placenta," and "hysteroscopy" were used for the identification of relevant studies. We included observational and randomized studies that analyzed surgical and/or reproductive outcomes of women who underwent hysteroscopic removal of RPOC. The primary outcome was the complete resection rate after 1 procedure. TABULATION, INTEGRATION, AND RESULTS: Twenty out of 245 studies were applicable, with data provided for 2112 women. The pooled complete resection rate was 91% (95% confidence interval [CI], 0.83-0.96). The incomplete resection rate evaluated was 7% (95% CI, 0.03-0.14), with a complication rate of 2% (95% CI, 0.00-0.04). Out of 1478 procedures, only 12 cases (0.8%) of postsurgical intrauterine adhesions were reported. Regarding post-therapy fecundity, women attempting postoperative conception had a clinical pregnancy rate of 87% (95% CI, 0.75-0.95), with a live birth rate of 71% (95% CI, 0.60-0.81) and a pregnancy loss rate of 9% (95% CI, 0.06-0.12). CONCLUSION: Hysteroscopy has a high rate of completely removing RPOC in a single surgical step, with low complication rates. Subsequent fecundity seems reassuring, with appropriate clinical pregnancy and live birth rates. However, standardization of approach and comparative trials of different hysteroscopic approaches are needed.

Management of anxiety and pain perception in women undergoing office hysteroscopy: a systematic review.

PURPOSE: The aim of this review is to provide an overview of the literature about the perception and management of anxiety and pain in women undergoing an office hysteroscopic procedure. METHODS: We performed a systematic literature search in Embase, PubMed/MEDLINE, Cochrane Library and Web of Science for original studies written in English (registered in PROSPERO 2019-CRD42019132341), using the terms 'hysteroscopy' AND 'pain' AND 'anxiety' published up to January 2019. Only original articles (randomized, observational and retrospective studies) about management of anxiety and pain related to the hysteroscopic procedure were considered eligible. RESULTS: Our literature search produced 84 records. After exclusions, 11 studies including 2222 patients showed the following results: (a) pain experienced during hysteroscopy is negatively affected by preprocedural anxiety; (b) pharmacological interventions seem to be help in reducing pain during hysteroscopy; (c) waiting time before the procedure is a significant factor affecting patients' anxiety; (d) music during the procedure may be helpful in reducing anxiety. CONCLUSIONS: The utilization of office hysteroscopy is hampered by varying levels of anxiety and pain perceived by women who are candidates for the procedure. For these reasons, it is essential to identify effective pharmacological and non-pharmacological strategies to alleviate these factors. We recommend further studies especially focusing on non-pharmacological interventions to facilitate the dissemination of good clinical practices among hysteroscopists.

Increased Fetal Chromosome Detection with the Use of Operative Hysteroscopy During Evacuation of Products of Conception for Diagnosed Miscarriage.

STUDY OBJECTIVE: To determine whether incorporation of operative hysteroscopy with biopsy of products of conception, in conjunction with a suction curettage for a first trimester missed abortion, affected the rate of maternal cell contamination when chromosomal analysis was performed on the products of conception, and to determine the rates of retained products of conception with incorporation of hysteroscopy after suction curettage. DESIGN: Retrospective chart study. SETTING: Private, minimally invasive surgery and infertility practice with academic-community hospital affiliation. PATIENTS: Infertility patients undergoing evacuation of products of conception for documented first trimester miscarriages between 2006 and 2017. INTERVENTIONS: Suction curettage or hysteroscopic biopsy and suction curettage, followed by chromosomal analysis of products of conception for determination of fetal genetics. MEASUREMENTS AND RESULTS: A total of 264 charts were analyzed. Patients were categorized into 2 groups based on surgical collection of products of conception: group 1 (N = 174), suction curettage only, and group 2 (N = 90), a single procedure consisting of operative hysteroscopy with biopsy of products of conception followed by suction curettage and then diagnostic hysteroscopy to look for retained products. Data for chromosome detection and retained products of conception were available for 246 and 239 patients, respectively. No significant differences were detected between the groups for age, body mass index, ethnicity, gravida, parity, primary infertility, secondary infertility, spontaneous conception, single or multiple gestation, and surgical complications. Fetal chromosome detection was significantly higher without maternal contamination in group 2 (88.5%) compared with group 1 (64.8%) (p < .001). There was no significant between-group difference in postoperative retained products of conception. CONCLUSION: Obtaining fetal genetics can be useful when planning for a future successful pregnancy. The addition of operative hysteroscopy to biopsy the gestational sac, chorionic villi, and/or fetus significantly decreases the risk of maternal contamination and increases the ability to detect fetal chromosomes for genetic analysis without an increased risk of surgical complications. Despite the low risk of surgical complications, immediate second-look hysteroscopy after the completion of suction evacuation does not reduce the risk of postoperative retained products of conception.

Employer-perspective cost comparison of surgical treatments for abnormal uterine bleeding.

Aim: To estimate direct and indirect costs of surgical treatment of abnormal uterine bleeding (AUB) from a self-insured employer's perspective. Methods: Employer-sponsored insurance claims data were analyzed to estimate costs owing to absence and short-term disability 1 year following global endometrial ablation (GEA), outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH). Results: Costs for women who had GEA are substantially less than costs for women who had either OPH or IPH, with the difference ranging from approximately $7700 to approximately $10,000 for direct costs and approximately $4200 to approximately $4600 for indirect costs. Women who had GEA missed 21.8-24.0 fewer works days. Conclusion: Study results suggest lower healthcare costs associated with GEA versus OPH or IPH from a self-insured employer perspective.

Economic Evaluation of Global Endometrial Ablation Versus Inpatient and Outpatient Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives.

Every year, abnormal uterine bleeding (AUB) exacts a heavy toll on women's health and leads to high costs for the US health care system. The literature shows that endometrial ablation results in fewer complications, shorter recovery and lower costs than more commonly performed hysterectomy procedures. The objective of this study was to model clinical-economic outcomes, budget impact, and cost-effectiveness of global endometrial ablation (GEA) versus outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH) procedures. A decision tree, state-transition (semi-Markov) economic model was developed to simulate 3 hypothetical cohorts of women who received surgical treatment for AUB (GEA, OPH, and IPH) over 1, 2, and 3 years to evaluate clinical and economic outcomes for GEA vs. OPH and GEA vs. IPH. Two versions of the model were created to reflect both commercial health care payer and US Medicaid perspectives, and analyses were conducted for both payer types. Total health care costs in the first year after GEA were substantially lower compared with those for IPH and OPH. Budget impact analysis results showed that increasing GEA utilization yields total annual cost savings of about $906,000 for a million-member commercial health plan and about $152,000 in cost savings for a typical-sized state Medicaid plan with 1.4 million members. Cost-effectiveness analysis results for both perspectives showed GEA as economically dominant (conferring greater benefit at lower cost) over both OPH and IPH in the 1-year commercial scenario. This study demonstrates that, for some patients, GEA may prove to be a safe, uterus-sparing, cost-effective alternative to OPH and IPH for the surgical treatment of AUB.

Digital Colposcopy With Dynamic Spectral Imaging for Detection of Cervical Intraepithelial Neoplasia 2+ in Low-Grade Referrals: The IMPROVE-COLPO Study.

OBJECTIVE: The aim of the study was to determine, in a wide "real-world" setting, whether digital colposcopy with adjunctive dynamic spectral imaging (DSI) mapping increases the detection of women with high-grade cervical intraepithelial neoplasia (CIN). MATERIALS AND METHODS: A multicenter, two-arm, observational, cross-sectional study that recruited women 21 years and older, having colposcopy after a low-grade abnormality screening result. The prospective arm collected outcomes of digital colposcopy with DSI used for identifying biopsy sites at the colposcopists' discretion. The retrospective control arm (number of subjects matched 1:1 per colposcopist) collected outcomes of standard colposcopy. The primary outcome was histopathological detection of women with CIN 2+ by colposcopic biopsy. RESULTS: The study included 1,788 women in the retrospective and 1,857 in the prospective arm from 39 US community-based clinics. Subject characteristics were comparable. A total of 71.6% of the women in the retrospective and 71.5% in the prospective arm underwent biopsy. The average number of biopsies increased from 1.032 (retrospective) to 1.256 (prospective). The yield of CIN 2+ patients was 7.21% in the retrospective and 9.48% in the prospective arm, a 2.27% difference (95% confidence interval = 0.47%-4.07%, p = .014) and 31.4% relative increase. The yield of CIN 3+ patients was 2.07% in the retrospective and 3.23% in the prospective arm, a 1.16% (95% confidence interval = 0.12%-2.24%, p = .031) absolute difference and 56.1% relative increase. The false-positive rates for biopsied patients were comparable (64.43% vs 62.04%, p = .139). CONCLUSIONS: Digital colposcopy with the adjunctive DSI increased CIN 2+ and CIN 3+ detection in low-grade referrals compared with standard colposcopy, with a similar number of women undergoing biopsy.

Resectoscopic Surgery for Polyps and Myomas: A Review of the Literature.

Resectoscopic surgery is routinely performed to remove endometrial polyps and uterine myomas. A search of Medline, PubMed, and the Cochrane Library was conducted through November 2016 for studies written in English, regardless of sample size or study type. The studies were then filtered by selecting those evaluating resectoscopic surgery. An analysis of peer-reviewed, published literature was performed to examine the clinical application of this treatment modality on patients requiring polypectomy and myomectomy. Different surgical techniques were also compared: hysteroscopy with scissors, forceps, or a cold loop; resectoscopy with radiofrequency energy; and mechanical resection. The literature finds that operative time during resectoscopic surgery is significantly longer than with mechanical resection. Resectoscopic myomectomy, however, may be necessary for removal of larger or more deeply embedded myomas. Ultimately, both techniques result in symptom resolution and a low recurrence rate.

Power Morcellation Using a Contained Bag System.

BACKGROUND AND OBJECTIVES: The well-known advantages of minimally invasive surgery make the approach well suited for hysterectomy and other gynecological procedures. The removal of specimens excised during surgery has been a challenge that has been answered by the use of power morcellation. With this study we sought to assess the feasibility of power morcellation within a specimen bag. METHODS: This was a retrospective cohort study including patients from a private practice in suburban Chicago, Illinois, who underwent contained electromechanical power morcellation during a laparoscopic or robot-assisted hysterectomy or myomectomy from May 2014 through December 2015. Contained power morcellation was performed with the Espiner EcoSac 230 (Espiner Medical Ltd., North Somerset, United Kingdom) specimen bag. Descriptive statistics were performed for both categorical and continuous data. RESULTS: Of the 187 procedures performed, 73.8% were myomectomies, and 26.2% were hysterectomies. The patients' mean age was 40 (range, 25-54) years and mean body mass index was 28.7 (range, 17.3-57.6). The average specimen weight was 300 g, with the largest weighing 2134 g. Estimated blood loss averaged 98.4 mL. The postoperative admission rate was 12.3%, most of which were due to nausea and urinary retention. Seventeen patients (9.1%) had postoperative complications, most of which were minor, and 4 (2.1%) were readmitted. There were no bag failures or complications that were due to the use of the specimen bag or to power morcellation. CONCLUSIONS: Performing electromechanical power morcellation within the Espiner EcoSac 230 specimen bag was successfully performed in 187 patients with no bag-related complications. This method of contained power morcellation is feasible, reliable, and reproducible, even for a large specimen.

Hysteroscopy safety.

PURPOSE OF REVIEW: Hysteroscopy is a very common tool providing the gynecologist the ability to diagnose and treat a variety of intrauterine disorders. This outpatient therapy has provided quick and effective relief for women worldwide. Although simple in concept, hysteroscopy is associated with minor and major complications. Awareness of these difficulties and methods of prevention and management is key to good surgical outcomes. This article reviews well tolerated practices for hysteroscopy complications. RECENT FINDINGS: Although complications with both diagnostic and operative hysteroscopy are rare, they can often be prevented with thorough preoperative evaluation and appropriate intraoperative decision making. Understanding the patient, disorder, and surgical process can assist the surgeon in providing the best outcome for the patient. SUMMARY: With appropriate training and education, gynecologists can safely incorporate hysteroscopy into their surgical practice.

Hysteroscopy for infertile women: a review.

Hysteroscopy is widely performed in infertile women. A review of peer-reviewed, published literature from the PubMed database on uterine intracavitary pathology, proximal tubal occlusion, failed in vitro fertilization procedures, and first trimester miscarriages of infertile women was performed to examine the importance, feasibility, and success rates of diagnostic and operative hysteroscopy when evaluating and treating these conditions.

Power morcellation in a specimen bag.

STUDY OBJECTIVE: To show a technique of power morcellation within a rip-stop nylon specimen bag. DESIGN: Step-by-step explanation of the technique. BACKGROUND: The Food and Drug Administration recently warned against the use of electromechanical power morcellation for hysterectomy and myomectomy because of potential tissue dissemination within the abdomen and pelvis. If the tumor is malignant, this technique increases the staging of the patient and may further warrant re-operation and chemotherapy. If the tumor is benign, the patient is at risk for parasitic myomas that may lead to, but are not limited to, pain and/or bowel obstruction. INTERVENTION: To reduce the preceding risks, we reviewed the techniques of power morcellation within a specimen bag used by other surgeons across the United States. This technique was modified to incorporate a more durable bag made out of rip-stop nylon. Laparoscopic supracervical hysterectomy during power morcellation was performed, along with an introduction to incorporating power morcellation of multiple myomas during a laparoscopic myomectomy. CONCLUSION: This technique of power morcellation within a rip-stop nylon bag minimizes the risk of inadvertent tissue spread. This allows the patient an opportunity to undergo minimally invasive surgery for hysterectomy and myomectomy.

Persistent bleeding after laparoscopic supracervical hysterectomy.

BACKGROUND AND OBJECTIVES: In our clinical experience, there seemed to be a correlation between cervical stump bleeding and adenomyosis. Therefore, we wanted to conduct a study to determine whether there was an actual correlation and to identify other risk factors for persistent bleeding after a laparoscopic supracervical hysterectomy. METHODS: The study included women who underwent laparoscopic supracervical hysterectomy from January 1, 2003, through December 31, 2012. Data were collected on age, postmenopausal status, body mass index (BMI), uterine weight, indication for hysterectomy, concomitant bilateral salpingo-oophorectomy (BSO), presence of endometriosis, surgical ablation of the endocervix, adenomyosis, presence of endocervix in the specimen, and postoperative bleeding. RESULTS: The study included 256 patients, of whom 187 had no postoperative bleeding after the operation, 40 had bleeding within 12 weeks, and 29 had bleeding after 12 weeks. The 3 groups were comparable in BMI, postmenopausal status, uterine weight, indication for hysterectomy, BSO, surgical ablation of the endocervix, adenomyosis, and the presence of endocervix. However, patients who had postoperative bleeding at more than 12 weeks were significantly younger (P = .002) and had a higher rate of endometriosis (P < .001). CONCLUSIONS: Risks factors for postoperative bleeding from the cervical stump include a younger age at the time of hysterectomy and the presence of endometriosis. Therefore, younger patients and those with endometriosis who desire to have no further vaginal bleeding may benefit from total hysterectomy over supracervical hysterectomy. All patients who are undergoing supracervical hysterectomy should be counseled about the possible alternatives, benefits, and risks, including continued vaginal bleeding from the cervical stump and the possibility of requiring future treatment and procedures.

Progressive reduction in abdominal hysterectomy rates: impact of laparoscopy, robotics and surgeon factors.

The objective of this study is to describe changes in rates of types of hysterectomy at a tertiary care community teaching hospital since the introduction of laparoscopic and robotic techniques and to determine the effect of surgeon characteristics on route of hysterectomy. This is a retrospective analysis of types of hysterectomies performed for benign disease during five different years (1989, 1994, 1999, 2004, 2009) at a large community teaching hospital. Hospital discharge data was reviewed to identify all hysterectomies performed during the first six months of each year of the study. Hospital charts were reviewed and patient characteristics, indication for surgery, type of hysterectomy and surgeon characteristics were recorded. Hysterectomies performed for malignancy, suspected malignancy, or postpartum hemorrhage were excluded. Types of hysterectomies included abdominal (AH), vaginal (VH), laparoscopic-assisted vaginal (LAVH), total laparoscopic (TLH), laparoscopic supracervical (LSH) and robotic-assisted (RH). The progressive introduction of newer minimally invasive surgical techniques (LAVH, TLH, LSH, and RH) resulted in an overall reduction in the abdominal hysterectomy rate from 77 to 35.2 % during the time of the study. The majority of abdominal, laparoscopic supracervical and robotic hysterectomies were performed by generalists, while the majority of vaginal, laparoscopic-assisted vaginal and total laparoscopic hysterectomies were performed by fellowship trained subspecialists. Minimally invasive hysterectomy techniques significantly reduced the rate of abdominal hysterectomies. The LSH and RH were the techniques utilized by generalists as their most preferred minimally invasive surgical approaches to hysterectomy.

Laparoscopic ureteral injury and repair: case reviews and clinical update.

Ureteral injuries are known complications of pelvic surgery. The incidence is 0.5% to 3%, and approximately one-third of these cases are not identified or corrected intraoperatively. It is critical to recognize and repair these injuries intraoperatively to decrease morbidity and prevent further complications, such as ureteral stricture, fistula formation, or loss of renal function. Traditionally, laparotomy has been the method of choice for ureteral injuries even when the injury is identified during a laparoscopic procedure. Laparoscopy has been shown to result in decreased infection rate, fewer incisional hernias, shorter hospital stay, and quicker recovery compared with laparotomy. Several articles were reviewed of successful laparoscopic ureteral injury repair, in addition to the 2 cases presented in this article. We conclude that laparoscopic ureteral injury repair is feasible, safe, and effective.

Spontaneous heterotopic triplets: a case report.

OBJECTIVE: To present a case report of a spontaneous, heterotopic, triplet conception of a patient without any risk factors. DESIGN: Case report. SETTING: Community hospital in Park Ridge, Illinois. PATIENT(S): One patient, 30-year-old multigravida, sent to the emergency room for evaluation of right lower quadrant pain after confirmed identification of an early, intrauterine pregnancy by an office ultrasound. The patient was taken to the operating room for suspected appendicitis and found to have a right ruptured ectopic pregnancy with a normal appendix. INTERVENTION(S): The patient underwent a laparoscopic right salpingostomy with hydrodissection of the ectopic pregnancy. MAIN OUTCOME MEASURE(S): Follow-up pelvic ultrasounds confirmed a viable, spontaneous twin intrauterine pregnancy. RESULT(S): The twin pregnancy continued without complications until 34 weeks' gestation, when the patient began preterm labor and delivered healthy twins. CONCLUSION(S): Even in the absence of infertility treatments and/or risk factors, heterotopic pregnancy should be included in the differential diagnosis for lower quadrant abdominal or pelvic pain.