Virtual sonographic hysteroscopy in assisted reproduction: A retrospective cost-effectiveness analysis

What is the impact of simulation on the learning of hysteroscopic skills by residents and medical students? A systematic review

INTRODUCTION

Hysteroscopy is a critical procedure in gynecology for diagnosing and managing intrauterine pathology. Traditional hands-on training faces ethical and safety challenges, leading to an increased reliance on simulation training. This review systematically assesses the effectiveness of hysteroscopic simulation training in enhancing the technical skills of obstetrics and gynecology residents and medical students.

METHODS

A PRISMA-guided literature search was conducted, covering English-language articles from January 2000 to December 2023. Studies were selected based on pre-defined criteria, focusing on the impact of simulation training on the targeted educational group. Metrics for evaluating skill improvement included machine-recorded metrics, Objective Structured Assessment of Technical Skills (OSATS), and global rating scales.

RESULTS

The review included nine studies with varied designs, demonstrating significant improvements in hysteroscopic skills following simulation training. Virtual reality (VR) simulators showed substantial benefits in skill acquisition, while physical simulators provided valuable tactile feedback. However, long-term skill retention and the impact on non-technical skills were not adequately assessed.

CONCLUSIONS

Simulation-based training effectively enhances hysteroscopic skills in medical students and residents. Further research is needed to explore long-term skill retention and the development of non-technical competencies. Robust studies, including randomized trials, are required for definitive validation.

Hysteroscopy: where did we start, and where are we now? The compelling story of what many considered the "Cinderella" of gynecological endoscopy

Hysteroscopy has truly revolutionized the field of diagnostic and operative gynecology. It is presently regarded as the gold standard method for both the diagnosis and treatment of intrauterine diseases and it has fundamentally altered the way gynecologists treat patients with such conditions. These pathologies can now be diagnosed and treated in an outpatient setting, thanks to technological advancements and instrument downsizing. Two hundred years of development and notable innovation are now reflected in the present hysteroscopic practice. This review attempts to trace the boundaries-pushing history of hysteroscopy by highlighting the advancements in technology and the therapeutic and diagnostic benefits offered by this groundbreaking approach.

TikTok as a platform for hysteroscopy information: An analytical video-based cross-sectional study to assess quality, reliability, and accuracy

OBJECTIVE

To assess the quality, reliability, and level of misinformation in TikTok videos about hysteroscopy.

METHODS

A cross-sectional analysis of TikTok videos retrieved using "hysteroscopy" as search term was performed. Patient education materials assessment tool for audio-visual content (PEMAT A/V), the modified DISCERN (mDISCERN), global quality scale (GQS), video information and quality index (VIQI) and misinformation assessment were used.

RESULTS

Of three hundred videos captured, 156 were excluded and 144 were included. Most videos were partially accurate or uninformative (43.8% and 34.7%, respectively). Non-healthcare providers produced more inaccurate or uninformative videos than healthcare workers (51.1% vs 4.0%; P < 0.001). Compared to content by professionals, content by patients showed increased distrust towards gynecologists (11.7% vs 0%; P = 0.012) and increased incidence of anxiety and concern towards hysteroscopy (25.5% vs 2%; P < 0.001). PEMAT A/V scores for understandability and actionability were low at 42.9% (interquartile range [IQR]: 11.1-70) and 0% (IQR: 0-0), respectively. Understandability (P < 0.001) and actionability (P = 0.001) were higher for professionals' created content relative to patients' videos. Similarly, median mDISCERN score was low (1 [IQR 0-2]), with significantly higher score for healthcare professionals compared to patients (P < 0.001). Overall video quality was also low, with median VIQI and GQS score of 7 (IQR 4-11) and 1 (IQR 1-3), respectively, and significantly higher scores for healthcare workers' captions compared to patients' for both (P < 0.001 and P = 0.001, respectively).

CONCLUSION

TikTok videos' quality on hysteroscopy seems unsatisfactory and misinformative, with low understandability and actionability scores. Videos recorded by healthcare workers show higher quality and less misinformation than those by patients. Raising the awareness regarding the low quality of medical information on social media is crucial to increase future reliability and trustworthiness.

The great debate: Surgical outcomes of laparoscopic versus laparotomic myomectomy. A meta-analysis to critically evaluate current evidence and look over the horizon

Myomectomy is one of the most common surgical procedure in the field of gynecology. However, the role of laparoscopic myomectomy is still debated for many factors, including surgical considerations, safety and fertility concerns, long-term outcomes, and cost-related issues. The aim of this study is to evaluate the surgical peri- and post-operative outcomes of laparoscopic and abdominal myomectomy. A systematic search for studies was performed up to June 2023 through MEDLINE, Pubmed, Embase. Studies reporting the comparison of surgical and obstetrical outcomes in laparoscopic versus laparotomic myomectomy were included for the following outcomes: time of surgery, estimated blood loss, decrease of postoperative hemoglobin, hospital stay, intra-operative complication rates, postoperative complications rates, postoperative analgesic use, postoperative pain at 24 h and pregnancy rate. The meta-analysis was performed using the Cochrane Review software. Fifty-six relevant articles were retrieved through the process of evidence acquisition. Eleven articles met inclusion criteria, for a total of 2,133 patients undergoing laparoscopic or laparotomic myomectomy. The estimated blood loss [standard mean differences (SMD) 0.72, IC 95 % 0.22 to 1.22], the hospital stays [SMD 3.12, IC 95 % 0.57 to 4.28], were significantly lower in laparoscopic than in open group. No statistically significant difference in intra-operative and post-operative complication rates, in pregnancy rate and others obstetrical outcomes between two surgical approaches were found. The findings of present metanalysis suggest that laparoscopic myomectomy offers multiple benefits, including reduced blood loss, shorter hospital stays, and less postoperative analgesic need, without a significant increase in complication rates and similar results in obstetrical outcomes when compared to abdominal myomectomy. However, the presence of few randomized studies on selected population may limit the generalizability of the findings to the entire population. Therefore, more well-designed studies or large population programdata to draw definitive conclusions are therefore warranted.

Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity

BACKGROUND

To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal.

PURPOSE

In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition.

METHODS

The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included.

RESULTS

Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments.

CONCLUSIONS

Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists.

C-section technique vs minilaparotomy after minimally invasive uterine surgery: a retrospective cohort study

PURPOSE

Uterine leiomyomas are benign uterine tumors. The choice of surgical treatment is guided by patient's age, desire to preserve fertility or avoid "radical" surgical interventions such as hysterectomy. In laparotomy, the issue of extracting the fibroid from the cavity does not arise. However, in laparoscopy and robotic surgery, this becomes a challenge. The aim of the present study was to determine the optimal surgical approach for fibroid extraction following laparoscopic or robotic myomectomy in terms of postoperative pain, extraction time, overall surgical time, scar size, and patient satisfaction.

METHODS

A total of 51 patients met the inclusion criteria and were considered in our analysis: 33 patients who had undergone the "ExCITE technique" (Group A), and 18 patients a minilaparotomy procedure (Group B), after either simple myomectomy, multiple myomectomy, supracervical hysterectomy, or total hysterectomy. The diagnosis of myoma was histologically confirmed in all cases.

RESULTS

Regarding the postoperative pain evaluation, at 6 h, patients reported 4 [3-4] vs 6 [5.3-7] on the VAS in Group A and B, as well as at 12 h, 2 [0-2] vs 3.5 [2.3-4] in Group A and B, respectively: both differences were statistically significant (p < 0.001). No statistically significant difference at 24 h from surgery was found. All patients in Group A were satisfied with the ExCITE technique, while in Group B only 67% of them. The length of the hospital stay was significantly shorter in Group A as compared to Group B (p = 0.007). In terms of the operative time for the extraction of the surgical specimen, overall operative time, and the scar size after the surgery, there was a statistically significant difference for those in Group A.

CONCLUSION

The ExCITE technique does not require specific training and allows the surgeon to offer a minimally invasive surgical option for patients, with also an aesthetic result. It is a safe and standardized approach that ensures tissue extraction without the need for mechanical morcellation.

Hysteroscopic versus histopathological agreement in the diagnosis of chronic endometritis: results from a retrospective observational study

PURPOSE

To evaluate the agreement rate between hysteroscopy and pathological examination in case of chronic endometritis.

METHODS

A retrospective observational study carried out at Gynecology and Obstetrics Department, Puerta de Hierro Hospital, Autónoma University of Madrid, Spain, from January 2021 to June 2022 was performed by obtaining data from 115 medical records of women who underwent office hysteroscopies that was compared with the findings of final histological examination of endometrial biopsy. Cohen's kappa index was used to evaluate this agreement rate. In addition, sensitivity, specificity, positive and negative predictive value and diagnostic accuracy were obtained.

RESULTS

The agreement between hysteroscopic findings and histological examination showed a modest result with a Cohen's kappa index of 34%. In addition, we obtained a specificity of 70% and a sensitivity of 64%. The positive and negative predictive value were 60.8% and 73.4%, respectively. An excellent agreement rate (100%) between histological and hysteroscopic results was observed in presence of hyperemia and micropolyps.

CONCLUSION

Although the sample size is not as large as that of other studies published so far, the first glance of our experience is that hysteroscopic signs are not yet sufficient to make an accurate diagnosis of chronic endometritis, thus requiring a histopathological confirmation to make it.

Diode laser use in hysteroscopic surgery: current status and future perspectives

Recent advances in surgical technology and innovative techniques have revolutionized surgical gynecology, including transcervical hysteroscopic procedures. Surgical lasers (Nd-Yag, Argon, diode, and CO2 lasers) have been promoted to remove a variety of gynecological pathologies. For hysteroscopic surgery, the diode laser represents the most versatile and feasible innovation, with simultaneous cut and coagulate action, providing improved hemostasis compared with CO2 laser. The newest diode laser devices exhibit increased power and a dual wavelength, to work precisely with reduced thermal dispersion and minimal damage to surrounding tissues. Their efficacy and safety have been validated both in the hospitals as well as in the office setting. Updated evidence reports that several hysteroscopic procedures, including endometrial polypectomies, myomectomies and metroplasties can be successfully performed with a diode laser. Therefore, this review aimed to give a deeper understanding of the role of laser energy in gynecology and subsequently in hysteroscopy in order to safely incorporate this technology into clinical practice.

Hysteroscopy in the new media: quality and reliability analysis of hysteroscopy procedures on YouTube™

BACKGROUND

Hysteroscopy plays a crucial role in diagnosing and managing various intrauterine pathologies. However, its execution can be influenced by patients' perception and understanding, which are often shaped by digital resources such as YouTubeTM. Given its popularity and accessibility, YouTubeTM has the potential to greatly influence patients' knowledge and expectations about this procedure, highlighting the need for accurate and reliable information.

PURPOSE

This study aims to assess the reliability and quality of hysteroscopy information available to patients on YouTubeTM. Understanding the nature of information patients' access can help address their fears and potential misunderstandings about the procedure, consequently reducing the likelihood of suspension or postponement due to anxiety.

METHODS

A comprehensive analysis of YouTubeTM was conducted, simulating the search process of a patient seeking information about hysteroscopy. The study evaluated the reliability and quality of 90 out of the first 100 hysteroscopy-related videos on YouTubeTM, scored by four gynecologists-two experienced hysteroscopists and two trainees. The videos were assessed for reliability and quality using the mDISCERN and Global Quality Scale (GQS) scores.

RESULTS

The average mDISCERN and GQS scores for the evaluated videos were below the optimal three points, highlighting the lack of fluency, comprehensiveness, and reliability of the available information. Notably, while videos produced by experts, including doctors and professional channels, had higher scores, they still fell short of the minimum score of 3. These videos also were not considered more suitable for either patients or trainees. Videos that were assessed as reliable (mDISCERN ≥ 3) were observed to be longer and were more frequently produced by doctors. These videos were suggested more to trainees rather than patients. Similarly, videos deemed as fluent and comprehensive (GQS ≥ 3) were longer and were more often recommended to patients.

CONCLUSIONS

While YouTubeTM is a widely used source of medical information, the quality and reliability of hysteroscopy videos on the platform are poor. The strategic use of selected, high-quality hysteroscopy videos can enhance procedure success and alleviate patient fears. However, the unsupervised discovery of information by patients could potentially lead to procedure failure or an elevated level of stress due to misleading or incorrect information.

Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review

BACKGROUND

Medically assisted reproduction (MAR) is a challenging application area for health economic evaluations, entailing a broad range of costs and outcomes, stretching out long-term and accruing to several parties.

PURPOSE

To systematically review which costs and outcomes are included in published economic evaluations of MAR and to compare these with health technology assessment (HTA) prescriptions about which cost and outcomes should be considered for different evaluation objectives.

DATA SOURCES

HTA guidelines and systematic searches of PubMed Central, Embase, WOS CC, CINAHL, Cochrane (CENTRAL), HTA, and NHS EED.

STUDY SELECTION

All economic evaluations of MAR published from 2010 to 2022.

DATA EXTRACTION

A predetermined data collection form summarized study characteristics. Essential costs and outcomes of MAR were listed based on HTA and treatment guidelines for different evaluation objectives. For each study, included costs and outcomes were reviewed.

DATA SYNTHESIS

The review identified 93 cost-effectiveness estimates, of which 57% were expressed as cost-per-(healthy)-live-birth, 19% as cost-per-pregnancy, and 47% adopted a clinic perspective. Few adopted societal perspectives and only 2% used quality-adjusted life-years (QALYs). Broader evaluations omitted various relevant costs and outcomes related to MAR. There are several cost and outcome categories for which available HTA guidelines do not provide conclusive directions regarding inclusion or exclusion.

LIMITATIONS

Studies published before 2010 and of interventions not clearly labeled as MAR were excluded. We focus on methods rather than which MAR treatments are cost-effective.

CONCLUSIONS

Economic evaluations of MAR typically calculate a short-term cost-per-live-birth from a clinic perspective. Broader analyses, using cost-per-QALY or BCRs from societal perspectives, considering the full scope of reproduction-related costs and outcomes, are scarce and often incomplete. We provide a summary of costs and outcomes for future research guidance and identify areas requiring HTA methodological development.

HIGHLIGHTS

The cost-effectiveness of MAR procedures can be exceptionally complex to estimate as there is a broad range of costs and outcomes involved, in principle stretching out over multiple generations and over many stakeholders.We list 21 key areas of costs and outcomes of MAR. Which of these needs to be accounted for alters for different evaluation objectives (determined by the type of economic evaluation, time horizon considered, and perspective).Published studies mostly investigate cost-effectiveness in the very short-term, from a clinic perspective, expressed as cost-per-live-birth. There is a lack of comprehensive economic evaluations that adopt a broader perspective with a longer time horizon. The broader the evaluation objective, the more relevant costs and outcomes were excluded.For several costs and outcomes, particularly those relevant for broader, societal evaluations of MAR, the inclusion or exclusion is theoretically ambiguous, and HTA guidelines do not offer sufficient guidance.

Hysteroscopic laser ablation of symptomatic uterine fibroids: insights from a prospective study

OBJECTIVE

This study aimed to evaluate the feasibility and efficacy of in-office hysteroscopic ablation of submucous uterine fibroids using a diode laser.

METHOD

A pilot study was conducted between January 2018 and January 2019 in a tertiary care university hospital. Patients with at least one symptomatic, class 0-2 FIGO classification, uterine fibroid ≤7 cm in size were eligible for inclusion. Evaluation of the changes in fibroid size and vascularity was performed using three-dimensional Doppler ultrasonography. Vaporization of the fibroid core was conducted using a 980-1470 nm wavelength diode laser inserted through the hysteroscope's working channel. The primary outcome was evaluation of the fibroid volume before and at 2 months after the procedure.

RESULTS

Twenty women were enrolled in the study. At 2-month follow-up, the volume of the fibroids was significantly reduced (51.6 ± 22.5 vs. 33.4 ± 17.1 mm3; p < 0.001). A major reduction of three-dimensional sonographic color Doppler vascularity (observed by the same operator and confirmed by four blind reviewers) was also achieved in 12/20 patients (60%; p = 0.03) while a reported symptom of heavy menstrual bleeding decreased from 18/20 (90%) to 2/18 (10%; p < 0.01).

CONCLUSION

Hysteroscopic laser ablation represents a feasible and effective alternative for treating women with symptomatic submucous fibroids in the office setting. Further studies with larger sample size and longer follow-up periods are needed to validate this promising technique.Key messageThis pilot study shows that in-office hysteroscopic laser ablation (HLA) could be a feasible alternative to treat symptomatic submucous uterine fibroids by coagulating their core, reducing their size and vascularization.

Hysteroscopic Findings and Operative Treatment: All at Once?

Hysteroscopy is considered not only a diagnostic instrument but also a therapeutic tool for many uterine pathologies. In the early 1990s, advances in technology and techniques made hysteroscopy less painful and invasive, allowing to increase in the number of gynecological procedures performed in an ambulatory setting without significant patient discomfort and with potentially significant cost savings. This is the so-called "office hysteroscopy" or "see-and-treat hysteroscopy", whose spread has permitted the decrease of the number of procedures performed in the operating room with the benefit of obviating the need for anesthesia and dilatation of the cervical canal.

Hysteroscopic Endometrial Ablation: From Indications to Instrumentation and Techniques-A Call to Action

The development of minimally invasive techniques has led to the creation of innovative alternatives in cases where traditional methods are not applicable. In modern gynecology, hysteroscopy has become the gold standard for the evaluation and treatment of intrauterine pathology. Endometrial ablation (EA) is a procedure that uses different types of energy to destroy the endometrium and is currently used as an alternative technique in cases of heavy menstrual bleeding when medical treatment has failed and uterine preservation is desired. The aim of this review was to evaluate the feasibility, safety, and clinical outcomes of hysteroscopic EA as an alternative in patients with abnormal uterine bleeding. A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 1994 to June 2022, to evaluate the outcomes in patients with abnormal uterine bleeding (AUB) undergoing EA using hysteroscopic and non-hysteroscopic techniques. Only scientific publications in English were included. Twelve articles on the current use of endometrial ablation were included. Data on patient symptoms, tools used for EA, primary outcomes, and adverse events were recorded. EA should be considered an effective and safe approach in the management of patients with abnormal uterine bleeding caused by benign pathology, in whom medical treatment has failed or is contraindicated. Due to the lack of evidence, it would be interesting to determine whether EA would also have a role in the treatment of women with premalignant lesions, avoiding invasive surgical procedures or medical treatment in those patients for whom hysterectomy or the use of hormonal treatment is contraindicated.

Abnormal Uterine Bleeding in Perimenopausal Women: The Role of Hysteroscopy and Its Impact on Quality of Life and Sexuality

Abnormal uterine bleeding (AUB) is a frequent symptom in perimenopausal women. It is defined as uterine bleeding in which the duration, frequency, or amount of bleeding is considered excessive and negatively affects the woman’s quality of life (QoL) and psychological well-being. In cases of structural uterine pathology, hysterectomy (usually performed via a minimally invasive approach) offers definitive symptom relief and is associated with long-lasting improvement of QoL and sexuality. However, over the past 30 years, uterus-preserving treatments have been introduced as alternatives to hysterectomy. Hysteroscopic polypectomy, myomectomy, or endometrial resection/endometrial ablation are minimally invasive techniques that can be used as an alternative to hysterectomy to treat AUB due to benign conditions. Although associated with high patient satisfaction and short-term improvement in their QoL, hysteroscopic treatments do not eliminate the risk of AUB recurrence or the need for further intervention. Therefore, considering the impact of different treatment options on QoL and sexuality during preoperative shared decision making could help identify the most appropriate and personalized treatment options for perimenopausal women suffering from AUB.

Ultra-minimally invasive surgery in gynecological patients: a review of the literature

In the last decade, Ultra-minimally invasive surgery (UMIS) including both minilaparoscopic (MH) and percutaneous (PH) endoscopic surgery achieved widespread use around the world. Despite UMIS has been reported as safe and feasible surgical procedure, most of the available data are drawn from retrospective studies, with a limited number of cases and heterogeneous surgical procedures included in the analysis. This literature review aimed to analyze the most methodologically valid studies concerning major gynecological surgeries performed in UMIS. A literature review was performed double blind from January to April 2021. The keywords ‘minilaparoscopy’; ‘ultra minimally invasive surgery’; ‘3 mm’; ‘percutaneous’; and ‘Hysterectomy’ were selected in Pubmed, Medscape, Scopus, and Google scholar search engines. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed for the drafting of the systematic review. The systematic literature research provided 298 studies, of which 9 fell within the inclusion criteria. Two hundred ninety-six total patients were included, 148 for both PH and MH groups. Median age (48 years), BMI (24 kg/m²), OT (90 min), EBL (50 ml), time to discharge (1 day), self scar evaluation (10/10), and VAS (3/10) were reported. The most frequent intraoperative complication in both the PH and MH groups was surgical bleeding. The UMIS approaches were feasible and safe even for complex gynecological procedures. Operative times and complications were superimposable to the “classical” minimally invasive approaches reported in the literature. The reported results apply only to experienced surgeons.

Novel diagnostic approaches to intrauterine neoplasm in fertile age: sonography and hysteroscopy

Endometrial carcinoma (EC) is the most common gynecological malignancy in the world. It is mostly detected in postmenopausal women, but it can also occur in women of fertile age who need fertility-sparing therapy. An early diagnosis is the main objective for the correct management of these patients, making it possible to use a fertility-sparing treatment approach without exposing the patients to the risk of cancer progression. In this review, we discuss the role of sonography and hysteroscopy in the detection of intrauterine neoplasm in women of childbearing age.