Pain in office hysteroscopy: it is not just a matter of size. Comment on: "Paulo AA, Solheiro MH, Paulo CO. Is pain better tolerated with mini-hysteroscopy than with conventional device? A systematic review and meta-analysis: hysteroscopy scope size and pain. Arch Gynecol Obstet. 2015 May 7"

Training in Diagnostic Hysteroscopy: The "Arbor Vitae" Method

Background and Objectives: Diagnostic hysteroscopy is the gold standard in the diagnosis of intrauterine pathology and is becoming an essential tool in the daily practice of gynecology. Training programs for physicians are necessary to ensure adequate preparation and learning curve before approaching patients. The aim of this study was to describe the "Arbor Vitae" method for training in diagnostic hysteroscopy and to test its impact on the knowledge and skills of trainees using a customized questionnaire. Materials and Methods: A three-day hysteroscopy workshop combining theory and practical "hands on "sessions with dry and wet labs has been described. The aim of the course is to teach indications, instruments, the basic principles of the technique by which the procedure should be performed, and how to recognize and manage the pathologies that can be identified by diagnostic hysteroscopy. To test this training method and its impact on the knowledge and skills of the trainees, a customized 10-question questionnaire was administered before and after the course. Results: The questionnaire was administered to 34 participants. All trainees completed the questionnaire, and no missing responses were recorded. Regarding the characteristics of the participants, 76.5% had less than 1 year of experience in performing diagnostic hysteroscopy and 55.9% reported performing fewer than 15 procedures in their career. For 9 of the 10 questions embedded in the questionnaire, there was a significant improvement in the scores between pre- and post-course, demonstrating a perceived significant improvement in theoretical/practical skills by the trainees. Conclusions: The Arbor Vitae training model is a realistic and effective way to improve the theoretical and practical skills required to perform correct diagnostic hysteroscopy. This training model has great potential for novice practitioners to achieve an adequate level of proficiency before performing diagnostic hysteroscopy on live patients.

Impact of endometrial sampling technique and biopsy volume on the diagnostic accuracy of endometrial cancer

BACKGROUND

Histotype and tumor grading of endometrial cancer are the most important factors that have to be assessed by preoperative endometrial sampling, and their concordance with the final surgical and definitive histological findings is of paramount importance. We aim to compare histotype and tumor grading concordance of various endometrial sampling techniques (ESTs) and to investigate the role of endometrial volume biopsy.

METHODS

We performed a retrospective analysis of patients with apparent early stage endometrial cancer collecting demographic, clinical data, type of EST, pathological characteristics of endometrial biopsies and final specimens. We classified ESTs as dilation and curettage (D&C), diagnostic hysteroscopy with D&C, outpatient hysteroscopy and operative hysteroscopy with or without D&C. Diagnostic and operative hysteroscopy were performed with Bettocchi's 5 mm hysteroscope. We evaluated concordance for histotype, and tumor grading, and we performed subgroup analysis based on the technique and final tumor grading. Concordance was classified from good, moderate, sufficient, fair, poor and none using Cohen k-statistic. Finally, we investigated the existence of independent risk factors for discordant tumor grading using multivariate binary logistic regression.

RESULTS

We collected 148 patients and of these 131 (88.5%) were diagnosed with endometrioid histotype and 65 (44%), 46 (31%) and 37 (25%) respectively with well, moderate and poor differentiated tumors. Atypical hyperplasia (AH) was detected preoperatively in 28 patients (19%). Histotype concordance was fair (k=0.35) and tumor grading concordance was moderate (k=0.45); particularly, concordance was fair in well-differentiated cases (k=0.38); concordance was moderate in moderate- and poor-differentiated cases (k=0.52) and good (k=0.71). Operative hysteroscopy showed moderate concordance for histotype (k=0.41), while grading concordance was fair for G1 (k=0.41), moderate for G2 (k=0.58) and good for G3 (k=0.72), regardless the use of D&C. Preoperative volume biopsy did not impact the concordance of tumor grading, while the adoption of operative hysteroscopy (with or without D&C) decreased the risk of grading discordance in G3 tumors (HR 0.17; 95% CI: 0.03-0.94; P=0.04). Conversely, time elapsed from diagnosis to treatment in well-differentiated tumors increased the risk of discordant results (HR 1.06; 95% CI: 1.02-1.52; P=0.04).

CONCLUSIONS

Operative hysteroscopy demonstrated the best tumor grading concordance, especially in poor-differentiated tumors. The volume of biopsy did not affect the tumor grading concordance.

Evaluation of the effects of dexmedetomidine and remifentanil on pain with the analgesia nociception index in the perioperative period in hysteroscopies under general anesthesia. A randomized prospective study

Objectives To compare analgesia nociception index (ANI) values, visual analog scale (VAS) values, and hemodynamic parameters in hysteroscopy patients who received remifentanil and dexmedetomidine during general anesthesia. Methods: In total, 30 patients who underwent hysteroscopy between March and September 2016 at the University of Health Sciences Fatih Sultan Mehmet Health Research and Application Center, Ankara, Turkey were included in this prospective study. Standard hemodynamic monitoring, ANI, and bispectral index (BIS) monitoring were applied to the patients. At 10 min prior to induction, 1 μg/kg of remifentanil was applied in Group R (n=15) and 1 μg/kg of dexmedetomidine was applied in Group D (n=15). After induction, sevoflurane was used for maintenance with dexmedetomidine at 0.2-0.7 μg/kg/hour in Group D and remifentanil at 0.05-0.5 μg/kg/minute in Group R. Perioperative and postoperative analgesia levels (ANI and VAS, respectively), hemodynamics, and complications were recorded. Results: Even though the ANI levels in Group D were lower at the perioperative 5th and 10th minutes, the ANI values were between the targeted limits, except for the measurement after I-gel insertion, in both groups. Hemodynamic parameters were within normal limits, but the mean arterial pressures in Group R after induction, following I-gel placement, and at the perioperative 5th, 10th, and 20th minutes were lower and at postoperative 30th minute were significantly higher.   Conclusion: Dexmedetomidine and remifentanil are both efficacious agents for perioperative analgesia in hysteroscopy cases.