Ambulatory hysteroscopy: evidence-based guide to diagnosis and therapy

Efficacy, safety, and feasibility of the treatment of intrauterine pathologies with the mini-resectoscope: A systematic review

BACKGROUND

Hysteroscopy represents the gold standard for the diagnosis and treatment of intrauterine pathologies. The advent of the mini-resectoscope heralded a new era in intrauterine surgery, both in inpatient and outpatient settings.

OBJECTIVES

To evaluate the effectiveness, safety, and feasibility of the mini-resectoscope for the treatment of intrauterine pathologies.

SEARCH STRATEGY

Electronic databases were searched for English-language trials describing surgical procedures for uterine pathologies performed with a mini-resectoscope until 30 April 2023.

SELECTION CRITERIA

Retrospective or prospective original studies reporting the treatment of uterine pathologies with mini-resectoscope were deemed eligible for the inclusion.

DATA COLLECTION AND ANALYSIS

Data about study features, characteristics of included populations, surgical procedures, complications, and results/outcomes were collected.

RESULTS

Seven papers that met the inclusion criteria were included in this systematic review. Quantitative analysis was not possible due to data heterogeneity. A descriptive synthesis of the results was provided accordingly to the pathology hysteroscopically removed/corrected: polyps and myomas, uterine septum, intrauterine synechiae, and isthmocele.

CONCLUSIONS

The mini-resectoscope is poised to play a leading role in hysteroscopic surgery for many pathologies, both in inpatient and outpatient settings. Since some applications of the mini-resectoscope have not yet been thoroughly investigated, future studies should address current knowledge gaps, designing high-quality comparative trials on specific applications.

Outpatient hysteroscopy: Suitable for all? A retrospective cohort study of safety, success and acceptability in Australia

BACKGROUND

In Australia, gynaecologists continue to assess and investigate abnormal uterine bleeding with inpatient hysteroscopy despite evidence validating outpatient hysteroscopy services.

AIM

This retrospective cohort study assessed the safety, success and acceptability of office hysteroscopy in a gynae-oncology rapid-access clinic over six years in Sydney, Australia, and included all women without an age or body mass index (BMI) cut-off using a 'see and treat' concept.

METHODS

A database was created and analysed retrospectively for patients who attended office hysteroscopy service between January 2016 and March 2021 (63 months, 481 eligible). An anonymous modified PAT-32 patient satisfaction questionnaire was also offered to an initial cohort after their procedure to gauge insightful feedback about acceptability.

RESULTS

A total of 92% of patients had successful outpatient hysteroscopic access; 24% of cases required hysteroscopy under general anaesthesia (GA) despite pathology in over 50% of cases; 68% of the total were able to be managed with outpatient hysteroscopy and did not require a follow-up GA hysteroscopy. This paper is also the first of its kind to our knowledge to incorporate patients >65 years, those with a BMI >35 and those with a history of cervical stenosis. This study suggests that age and BMI do not impact the success rate of the procedure.

CONCLUSION

This study demonstrates that outpatient hysteroscopy is an acceptable, safe procedure that is well tolerated by patients. Considering our rapid-access hysteroscopy service allowed 68% of the patient cohort to avoid hysteroscopy under GA, we estimate conservatively ~$63 million per year in Australia could be saved by performing office hysteroscopies.

Use of Diode Laser in Hysteroscopy for the Management of Intrauterine Pathology: A Systematic Review

Background: Hysteroscopy currently represents the gold standard for the diagnosis and treatment of intrauterine pathologies. Recent technological progress has enabled the integration of diagnostic and operative time, leading to the "see and treat" approach. Diode laser technology is emerging as one of the most innovative and intriguing techniques in this context. Methods: A comprehensive search of the literature was carried out on the main databases. Only original studies reporting the treatment of intrauterine pathologies using diode laser were deemed eligible for inclusion in this systematic review (PROSPERO ID: CRD42023485452). Results: Eight studies were included in the qualitative analysis for a total of 474 patients undergoing laser hysteroscopic surgery. Eighty-three patients had female genital tract abnormalities, 63 had submucosal leiomyomas, 327 had endometrial polyps, and one patient had a scar pregnancy. Except for leiomyomas, whose technique already included two surgical times at the beginning, only seven patients required a second surgical step. Cumulative rates of intraoperative and postoperative complications of 2.7% and 0.6%, respectively, were reported. Conclusions: Diode laser through "see and treat" hysteroscopy appears to be a safe and effective method. However, additional studies with larger sample sizes and improved designs are needed to consolidate the evidence currently available in the literature.

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.

Hysteroscopic Identification of Intrauterine Pathology in Oocyte Donation Cycles: A Retrospective Study

BACKGROUND

Hysteroscopy remains the gold standard for the diagnosis and treatment of intracavitary uterine anomalies. As for recipients where oocyte donation is mandatory, accurate evaluation of previously missed intrauterine pathology may be an important step to optimize implantation process. The aim of this study was to hysteroscopically assess the incidence of unidentified intrauterine pathology prior to embryo transfer in an oocyte recipient population.

METHODS

A retrospective descriptive study was conducted between 2013 and 2022 at Assisting Nature In Vitro Fertilization (IVF) Centre in Thessaloniki, Greece. The study population consisted of oocyte recipient women who underwent hysteroscopy one-three months before embryo transfer. Furthermore, oocyte recipients after repeated implantation failure were investigated as a subgroup. Any identified pathology was treated accordingly.

RESULTS

In total, 180 women underwent diagnostic hysteroscopy prior to embryo transfer with donor oocytes. The mean maternal age at the time of intervention was 38.9 (+5.2) years, while the mean duration of infertility was 6.03 (+1.23) years. Additionally, 21.7% (n=39) of the study population had abnormal hysteroscopic findings. In particular, congenital uterine anomalies (U1a: 1.1% {n=2}, U2a: 5.6% {n=10}, U2b: 2.2% {n=4}) and polyps (n=16) were the main findings in the sample population. Furthermore, 2.8% (n=5) had submucous fibroids and 1.1% (n=2) were diagnosed with intrauterine adhesions. Notably, in recipients after repeated implantation failure intrauterine pathology rates were even higher (39.5%).

CONCLUSIONS

Oocyte recipients and especially those with repeated implantation failures probably have high rates of previously undiagnosed intrauterine pathology so, hysteroscopy would be justified in these subfertile populations.

Vibrational Biospectroscopy: An Alternative Approach to Endometrial Cancer Diagnosis and Screening

Endometrial cancer (EC) is the sixth most common cancer and the fourth leading cause of death among women worldwide. Early detection and treatment are associated with a favourable prognosis and reduction in mortality. Unlike other common cancers, however, screening strategies lack the required sensitivity, specificity and accuracy to be successfully implemented in clinical practice and current diagnostic approaches are invasive, costly and time consuming. Such limitations highlight the unmet need to develop diagnostic and screening alternatives for EC, which should be accurate, rapid, minimally invasive and cost-effective. Vibrational spectroscopic techniques, Mid-Infrared Absorption Spectroscopy and Raman, exploit the atomic vibrational absorption induced by interaction of light and a biological sample, to generate a unique spectral response: a “biochemical fingerprint”. These are non-destructive techniques and, combined with multivariate statistical analysis, have been shown over the last decade to provide discrimination between cancerous and healthy samples, demonstrating a promising role in both cancer screening and diagnosis. The aim of this review is to collate available evidence, in order to provide insight into the present status of the application of vibrational biospectroscopy in endometrial cancer diagnosis and screening, and to assess future prospects.

Risk of atypical hyperplasia and endometrial carcinoma after initial diagnosis of non-atypical endometrial hyperplasia: A long-term follow-up study

OBJECTIVES

The strong association between atypical endometrial hyperplasia and endometrial carcinoma is well established, but data on the risk of atypical hyperplasia and carcinoma in Danish women with non-atypical endometrial hyperplasia are almost non-existent. This study aimed to investigate the prevalence of atypical hyperplasia and endometrial carcinoma diagnosed within 3 months of initial diagnosis (defined as concurrent disease) and the risk of atypical hyperplasia and carcinoma more than 3 months after initial diagnosis (classified as progressive disease) in Danish women initially diagnosed with non-atypical endometrial hyperplasia.

DESIGN

This cohort study recruited 102 women diagnosed with non-atypical endometrial hyperplasia at Randers Regional Hospital in Randers, Denmark, between 2000 and 2015.

METHODS

The endometrium was evaluated by transvaginal ultrasound examination and office mini-hysteroscopy with biopsies in all non-hysterectomized women. Data regarding subsequent hysterectomy or endometrial sampling were obtained from medical records and the Danish Pathology Registry (Patobank).

RESULTS

A total of 15 women were diagnosed with atypical hyperplasia or carcinoma during follow-up. Concurrent atypical hyperplasia or carcinoma was seen in 2.9% (3/102), and among women who remained at risk for more than 3 months after initial diagnosis of non-atypical endometrial hyperplasia (n = 94), progression to atypical hyperplasia or carcinoma was seen in 13% (median follow-up 5.2 years, range 3.6 months to 15.1 years). Sixty-six percent of the women with progressive disease were diagnosed with atypical hyperplasia or carcinoma more than 1 year after initial diagnosis, but only two were diagnosed later than 5 years (5.2 and 9 years).

CONCLUSIONS

The risk of being diagnosed with atypical endometrial hyperplasia or endometrial carcinoma more than 5 years after an initial diagnosis of non-atypical endometrial hyperplasia seems to be low in Danish women. Specialized follow-up more than 5 years after diagnosis of non-atypical endometrial hyperplasia may not be warranted.

Increasing the adoption of ambulatory hysteroscopy in Australia - cost comparisons and patient satisfaction

We present the findings of a prospective cohort study in a single tertiary hospital to review the patient experience and economic benefit of ambulatory hysteroscopy (AH). Data were collected between May 2017 and February 2020. Patient satisfaction was measured with qualitative survey. Hospital level financial data were obtained over two financial years (2017/18 and 2018/19) to identify seasonal variation. The primary outcome was patient satisfaction and the secondary outcome was cost of AH compared to hysteroscopy under GA. Three hundred and twenty-nine patients underwent AH. Two hundred and ninety-eight responses (91%) were collected. Ninety-five percent of procedures were successful. Median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it. The average hospital cost for AH was $259 compared with $3098 for hysteroscopy under GA. These findings support AH as a safe, well-tolerated and economically viable alternative to hysteroscopy under GA.Impact StatementWhat is already known on this subject? Hysteroscopy is traditionally performed in an operating theatre under general anaesthesia (GA). Technological advancements allow for the procedure to be performed in an outpatient setting. Despite advantages of ambulatory hysteroscopy (AH), GA hysteroscopy is still the predominant intervention in Australia.What the results of this study add? Patient satisfaction in AH was assessed. The median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it.What the implications are of these findings for clinical practice and/or further research? AH is a well-tolerated alternative to hysteroscopy under GA with significant cost benefits to the hospital and high patient satisfaction. Further research should focus on direct comparison of the two procedure approaches using randomised controlled trials.

Hysteroscopy as An Investigational Operative Procedure in Primary and Secondary Infertility: A Systematic Review

Background

The aim of this study is to review current indications to diagnostic and/or operative hysteroscopy in primary and secondary infertility, as well as to determine its efficacy in improving fertility.

Materials and Methods

We gathered available evidence about the role of hysteroscopy in the management of vari- ous infertility conditions. Literature from 2000 to 2020 that pertained to this topic were retrieved and appropriately selected.

Results

Hysteroscopy does not appear as a first line diagnostic procedure for every clinical scenario. However, its di- agnostic sensitivity and specificity in assessing intrauterine pathology is superior to all other non-invasive techniques, such as saline infusion/gel instillation sonography (SIS/GIS), transvaginal sonography (TVS) and hysterosalpingog- raphy (HSG). Hysteroscopy allows not only a satisfactory evaluation of the uterine cavity but also, the eventual treat- ment of endocavitary pathologies that may affect fertility both in spontaneous and assisted reproductive technology (ART) cycles.

Conclusion

Hysteroscopy, due to its diagnostic and therapeutic potential, should be regarded as a necessary step in infertility management. However, in case of suspected uterine malformation, hysteroscopy should be integrated with other tests [three-dimensional (3D) ultrasound or magnetic resonance imaging (MRI)] for diagnostic confirmation.

Multiparametric transvaginal ultrasound in the diagnosis of endometrial cancer in post-menopausal bleeding: diagnostic performance of a transvaginal algorithm and reproducibility amongst less experienced observers

OBJECTIVE

(a) To comparatively evaluate the performance of grayscale ultrasound features, power Doppler (PD) blood flow characteristics, and gel infusion sonography (GIS) in diagnosing endometrial cancer during real-time examination, (b) to compare the performance of real-time diagnosis of endometrial cancer by experienced observers with offline analysis by blinded observers using similar sonographic criteria during review of cine loop clips.

METHODS

152 females with post-menopausal bleeding (PMB) had ET ≥ 4 mm at first-line ultrasound were included. Two experienced radiologists evaluated endometrial patterns at real-time evaluation (grayscale ultrasound, PD, and GIS), then examinations were stored as video clips for later evaluation by two less-experienced radiologists. The reference standard was hysteroscopy (HY) and/or hysterectomy with the histopathological examination. The area under (AUC) the receiver operating characteristic (ROC) curve was calculated to assess the diagnostic performance for the prediction of endometrial cancer.

RESULTS

Among 152 females with ET ≥ 4 mm at first line TVUS, 88 (57.9%) patients had endometrial cancer on final pathologic analysis. Real-time ultrasound criteria (ET ≥ 5 mm with the presence of irregular branching endometrial blood vessels or multiple vessels crossing EM or areas with densely packed color-splash vessels with non-intact or interrupted EMJ at the grayscale ultrasound and/or GIS) correctly diagnosed 95% of endometrial cancers with 92% diagnostic efficiency.There is comparable accuracy of real-time evaluation (96%) and offline analysis (92%) after the exclusion of poor quality videos from the analysis. The diagnostic criteria showed good to an excellent agreement between real-time ultrasound and offline analysis.

CONCLUSION

When real-time ultrasound is performed with good technique, utilizing multiple parameters, it is possible to diagnose endometrial cancer with a high degree of accuracy and reproducibility.

ADVANCES IN KNOWLEDGE

when real-time ultrasound is performed with good technique, utilizing multiple parameters, it is possible to diagnose endometrial cancer with a high degree of accuracy and reproducibility.

Office hysteroscopy: back to the future!

Hysteroscopy and anesthesia have come a long way in the last 150 years. While traditionally performed in the operating theater under general anesthesia, the alternative approach - so-called 'office' hysteroscopy - has gained popularity in recent years. Supporters of this modality cite the 'see and treat' capabilities, avoidance of anesthesia, more rapid turn-around time, and favorable economics as advantages. On the other hand, some question the success rate, capabilities, and patient comfort levels as potential drawbacks. In this article, we review the evidence behind all of these points as well as the requirements for setting up an office hysteroscopy service.

Clinical recurrence of submucosal myoma after a mechanical hysteroscopic myomectomy: Review after 5 years follow up

OBJECTIVE

Evaluation of five years follow up of the clinical recurrence after hysteroscopic myomectomies with MyoSure® morcellator in our district.

STUDY DESIGN

Premenopausal patients from April 2013 to October 2018, with symptoms of abnormal uterine bleeding, and/or infertility, and sonographic suspicion of submucosal myoma, confirmed by diagnostic hysteroscopy prior to myomectomy were included in the prospective, not randomized cohort study (N = 320). All patients had a follow up visit between three to six months post procedure. Further follow up was established by chart review. The information was extracted from the medical records. Patient characteristics were expressed as mean ± SD or median (interquartile range) for continuous data (assumption of normality assessed using the Kolmogorov-Smirnov test). Dependence relationship between presence of corporal myomas and the performance of a major long-term surgery, and between the amount of submucosal myomas and clinical recurrence throughout the 5 years of follow-up were studied were studied by χ².

RESULTS

After one year follow up, no recurrence or symptoms were noted. 53 (16.6%) re-morcellations were performed due to incomplete resection. At the second year, three women who were discharged previously were classified as recurrence (0.9%). There were 99 women remaining to be evaluated (30.90%) in the second year. A percentage estimation of 5-6 recurrences with the 100% of women evaluated. In the third year, only one woman was classified as recurrence (0.3%), with 176 (55%) women not evaluated. At the fourth and fifth year of follow-up, 75% are still awaiting complete of the study five years. No relationship was observed in the presence of corporal myomas and recurrence throughout the 5 years of follow-up (χ² = 0.000, p = 0.994). Dependence relationship was observed between the presence of corporal myomas and the performance of a major long-term surgery (χ² = 11.757, p = .001, OR = 3.528).

CONCLUSION

In office hysteroscopic mechanical myomectomy with MyoSure® morcellator of submucosal fibromas was a highly effective therapy for women, at three years of follow-up. It appears to give satisfactory long-term results with a low recurrence rate and without significant complications.

Efficacy of Antibiotic Prophylaxis for Hysteroscopy: A Meta-Analysis of Randomized Trials

OBJECTIVE

To assess the efficacy and side effects of antibiotic prophylaxis compared with placebo or no treatment in women undergoing hysteroscopy.

DATA SOURCES

A structured search was carried out in PubMed-Medline, Embase, and Cochrane Controlled Trials Register databases through December 31, 2018.

METHODS OF STUDY SELECTION

The search included a combination of the following terms: "hysteroscopy," "endoscopic surgery," "antibiotic prophylaxis." The following outcomes were selected: postoperative fever, infection rate, pelvic inflammatory disease (PID) and abscess occurrence, postoperative antibiotic requirement, and side effects occurrence (lower abdominal pain, vomiting, diarrhea, anaphylactic reaction). A random-effects model was used at meta-analysis. Study quality and bias risk were assessed with the Cochrane tool.

TABULATION, INTEGRATION, AND RESULTS

Five randomized controlled trials comparing efficacy of antibiotic prophylaxis with placebo or no treatment were included in the meta-analysis. Overall, pooled incidence of events was very low in both groups (fever, 3.79% vs 1.8%; overall infection, .52% vs .58%; postoperative antibiotic therapy, 1.18% vs 1.32%; and lower abdominal pain, 12.46% vs 9.31%). Moreover, the incidence of serious infections requiring further actions (PID or abscess) appeared to be extremely low (.2% in pretreated women and none in control groups). No one trial individually or the pooled analysis showed a statistically significant benefit of antibiotics prophylaxis over placebo for the outcome considered.

CONCLUSION

The use of antibiotics appears not to be beneficial to prevent infection after hysteroscopy; however, the lack of high-quality studies makes it difficult to draw firm conclusions. Considering the very low infection rate highlighted after hysteroscopic procedures, a difference will probably never be proven in a randomized trial. A larger population and program data to confirm these results are therefore warranted.

Application of 'no-touch' hysteroscopy (vaginoscopy) for the treatment of abnormal uterine bleeding in adolescence

AIM

This article retrospectively analyzed the efficacy and safety of vaginoscopy in the treatment of adolescent abnormal uterine bleeding (AUB) in 204 cases of AUB.

METHOD

From January 1, 2007 to December 31, 2017, 204 patients with intact hymen who were admitted to our hospital due to AUB received vaginoscopy, and vaginoscopy did not damage the hymen. In this study, 4.5 mm and 6.5 mm hysteroscopy were used with a pumping fluid pressure of 100-120 mm Hg and a flow rate of 400 mL/min. All 204 vaginoscopy was successfully completed in intravenous anesthesia.

RESULTS

Postoperative pathological examination confirmed that of the 204 patients, 53 patients had simple hyperplasia. There were 53 cases of polyps, 50 cases of endometrial gland hyperplasia and disordered arrangement, 35 cases of proliferative phase endometrium, five cases of bleeding phase endometrium, partial glandular secretion, three cases of complex hyperplasia and one case of decidua like change. Follow-up data from 64 patients showed that 34 patients were effective after treatment. Stepwise logistic regression analysis suggested that endometrial thickness was associated with treatment outcome (HR, 0.875, 95% CI, 0.786-0.974, P = 0.014). There was no significant difference in drug use between patients with effective and ineffective treatment.

CONCLUSION

'No-touch' vaginoscopy is feasible for the diagnosis and treatment of adolescent AUB without destroying the intact hymen.

Histopathology and Clinical Outcomes of 151 Women with Postmenopausal Bleeding Treated with Resectoscopic Surgery

STUDY OBJECTIVE

Because postmenopausal bleeding (PMB) is associated with up to 10% of endometrial neoplasia and office endometrial sampling fails in approximately 10% and is inadequate in 30% of cases, the objective was to determine the role of hysteroscopic endometrial resection (HER) for the diagnosis and treatment of women with PMB.

DESIGN

A retrospective cohort.

SETTING

A university-affiliated teaching hospital.

PATIENTS

One hundred fifty-one women with PMB (September 1990-December 2010).

INTERVENTION

HER in the operating room.

MEASUREMENTS AND MAIN RESULTS

The median (range) age and body mass index were 58 (50-87) years and 29 (21-52) kg/m², respectively. Office endometrial biopsy failed in 30 (19.8%), was inadequate in 20 (13.2%), identified nonatypical endometrial hyperplasia (NAH) in 21 (14%), atypical hyperplasia (AH) in 4 (2.6%), and endometrial cancer (EC) in 2 (1.3%) women. HER in 151 women identified 7 new cases of AH (3 from failed/inadequate office biopsy and 4 from NAH) and 9 EC (5 from failed/inadequate office biopsy, 1 from proliferative endometrium, 2 from NAH, and 1 from AH). All 27 women with NAH were treated by HER alone. Of 8 women with AH, 6 were treated with HER and 2 with hysterectomy; no residual endometrium was found in hysterectomy specimens. Of the 11 women with EC, 2 refused hysterectomy and are well 10 and 15 years after HER. Hysterectomy was performed for 9 of 11 EC cases, 2 of 8 AH cases, and 1 for abnormal uterine bleeding. Six women had repeat HER for persistent abnormal uterine bleeding, and 10 were lost to follow-up. At a median follow-up of 11.5 years (range, 7-20 years), 132 (12 hysterectomies + 10 lost) of 151 (87.4%) women were satisfied with no further bleeding.

CONCLUSION

In women with PMB, hysteroscopic endometrial resection concomitantly with resection of intrauterine pathology by experienced surgeons is feasible, safe, and effective for diagnosis in all cases and treatment of the majority of intrauterine pathology including NAH and selected cases of AH and EC.

Suprapubic pressure facilitates the procedure of office hysteroscopy: A randomized controlled trial

AIM

To minimize the experienced pain during office hysteroscopy, a number of technical approaches and maneuvers are used. The aim of the study was to assess the effect of suprapubic pressure (SuPuP) applied during hysteroscopy. The impact of this maneuver on experienced pain (assessed by visual analog scale [VAS]) and duration of passage through the cervical canal was measured and compared to a reference group with no SuPuP.

METHODS

Hysteroscopy was performed in study subjects as part of their infertility work-up. Patients were randomized into two groups as part of a controlled trial. In group 1, SuPuP was applied while inserting the scope; in group 2, SuPuP was not applied. Pain experienced during the procedure was measured on a 0-10 VAS. Duration of passage through the cervical canal was measured by analyzing the video of the procedure. The effect of SuPuP was estimated by testing for between-groups differences in these outcomes.

RESULTS

The number of patients included the study was 60. Mean (SD) VAS score was 3.40 (1.276) in group 1 compared to 3.33 (0.802) in group 2 (P = 0.809). Mean (SD) time of passage through the cervical canal in group 1 was 30.5 (18.37) seconds compared to 43.0 (24.51) seconds in group 2 (P = 0.029).

CONCLUSION

Applying suprapubic pressure could facilitate the procedure by significantly shortening the duration of the passage through the cervical canal, but significantly not reduces the pain experienced during hysteroscopy. Further studies are to be undertaken to investigate the advantages of suprapubic pressure during office hysteroscopy.

Management of abnormal uterine bleeding - focus on ambulatory hysteroscopy

The rapid evolution in ambulatory hysteroscopy (AH) has transformed the approach to diagnose and manage abnormal uterine bleeding (AUB). The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting.

Is outpatient hysteroscopy the new gold standard? Results from an 11 year prospective observational study

BACKGROUND

In Australia, gynaecologists continue to investigate women with abnormal bleeding and suspected intrauterine pathology with inpatient hysteroscopy despite some evidence in the literature that that there is no difference in safety and outcome when compared to an outpatient procedure.

AIMS

This prospective study assessed the safety, effectiveness and acceptability of outpatient hysteroscopy over 11 years at a tertiary hospital in Australia. Resource savings were then calculated.

MATERIALS AND METHODS

A prospective database was analysed from March 2003 to January 2014 (130 months, 990 women).

RESULTS

Successful hysteroscopic access was obtained in 94% of cases. Twenty-six percent of patients required a second procedure, including 132 for endometrial polyps and 33 for submucosal fibroids that were not able to be treated in the outpatient setting. On questioning, 88% of women would be happy to have the procedure again. Factors affecting success were pre-procedure pain, menopausal status and previous vaginal delivery. The difference between pain experienced versus pain expected was a major factor in patient acceptability. A vasovagal episode occurred in 5% of cases.

CONCLUSION

Outpatient hysteroscopy was demonstrated to be safe, effective and acceptable to women. Provision of an outpatient hysteroscopy service saves theatre time and approximately $1000 per case. Improved techniques and technology will allow progression to a 'see and treat' service, providing further savings. With budget constraints, increasing wait times for major procedures and concerns about trainee surgical experience, an outpatient hysteroscopy service should be considered the 'gold standard' investigation over hysteroscopy in theatre.

Videovaginoscopy of the canine vagina

Endoscopy enables a rapid and non-traumatic examination of the vaginal cavity of female dogs. Its implementation requires specific equipment as well as knowledge about the species-specific vaginal anatomy and the procedure. Vaginoscopy is the diagnostic tool of choice for several vaginal conditions and diseases such as congenital abnormalities, neoplasia or ectopic ureter. Furthermore, vaginal inspection may provide additional information in cases of vulvar discharge or infertility. Vaginoscopy is a superior tool compared to other methods in assisted reproduction. Changes of the vaginal mucosa during the oestrous cycle can be observed to determine the hormonal actions and the time of ovulations in addition to other routine examinations, such as progesterone assay and vaginal cytology. Finally, intrauterine insemination, which is recommended for insemination with frozen-thawed semen, can be performed endoscopically by transcervical catheterization.

Endometrial study in patients with postmenopausal metrorrhagia

INTRODUCTION

The aim of the study was to devise a strategy to diagnose malign endometrial pathologies (adenocarcinoma or atypical hyperplasia) that minimizes the number of invasive tests done (hysteroscopy, aspiration biopsy or curettage) with no loss of its detection efficiency.

MATERIAL AND METHODS

We retrospectively studied the clinical histories of 779 postmenopausal women at the University Hospital Complex of Albacete, for whom an endometrial study had been done (hysteroscopy, aspiration biopsy or curettage) with a 1-year follow-up between 1 March 2006 and 31 March 2008.

RESULTS

There were 77 cases of a malignant pathology (66 adenocarcinomas and 11 hyperplasias with atypia); 96.1% had metrorrhagia, and there were only 3 cases of asymptomatic patients (all 3 presented endometrial thickness of > 5 mm: 10, 12 and 15 mm). The sensitivity and specificity of the transvaginal ultrasound, with a 5 mm cut-off point to diagnose a malignant pathology, were 98.4% and 30.1%, respectively; 89.1% and 99.6%, respectively, for aspiration biopsy; 83.9% and 99.1%, respectively, for hysteroscopy without biopsy; and both were 100% for biopsy. Statistical significance was considered at p < 0.05 and confidence intervals were calculated at 95%.

CONCLUSIONS

In postmenopausal women with metrorrhagia, the first action to take is to do a transvaginal ultrasound, followed by en endometrial study, but only if the endometrium is irregular or endometrial thickness is ≥ 5 mm; in asymptomatic women, the cut-off point should be set at 10 mm. The immediate method of choice is an ambulatory biopsy.

Reproducibility of Endometrial Pathologic Findings Obtained on Hysteroscopy, Transvaginal Sonography, and Gel Infusion Sonography in Women With Postmenopausal Bleeding

STUDY OBJECTIVE

To evaluate and compare interobserver variation in endometrial pattern recognition with hysteroscopy (HY) and transvaginal sonography (TVS) and gel infusion sonography (GIS) with regard to the diagnosis of endometrial pathology.

DESIGN

Prospective study (Canadian Task Force II-1).

SETTING

University clinic.

PATIENTS

One hundred twenty-two consecutive women with postmenopausal bleeding and an endometrium thickness ≥ 5 mm.

INTERVENTION

Two observers using HY and 2 others using TVS and GIS evaluated the endometrial pattern in recorded video clips. Interobserver agreement regarding findings obtained with TVS, GIS, and HY for a diagnosis of cancer, hyperplasia, polyps, and no endometrial pathology was expressed by κ coefficients and compared.

MEASUREMENT AND MAIN RESULTS

Interobserver agreement (κ) was as follows: identification of normal endometrium: HY (.74), TVS (.68), and GIS (.48); diagnosis of cancer: HY (.56), TVS (.59), and GIS (.34); classification in all categories of endometrial pathology: HY (.70), TVS (.47), and GIS (.41) (p < .05 HY vs GIS). The presence of additional endometrial polyps decreased agreement on HY in patients with hyperplasia or cancer. Observer agreement was poor regarding the diagnosis of hyperplasia by all techniques.

CONCLUSION

Observer agreement regarding both HY and TVS was reliable for the diagnosis of a normal endometrium but poor with HY, TVS, and especially GIS for a diagnosis of cancer. In patients with hyperplasia or cancer, agreement between observers was especially low in the presence of additional polyps when HY was used. These findings call attention to the need for systematic methods to improve reliability in endometrial pattern recognition.

Setting up of ambulatory hysteroscopy service

There is an obvious trend towards developing ambulatory procedures in gynaecology with ambulatory hysteroscopy as its mainstay. In the recent years, the fast pace of modern technological advances in gynaecologic endoscopy, and particularly in the field of hysteroscopy, have been both thrilling and spectacular. Despite this, the uptake of operative hysteroscopy in ambulatory settings has been relatively slow. There is some apprehension amongst gynaecologists to embark on therapeutic outpatient hysteroscopy, and an organisational change is required to alter the mindset. Although there are best practice guidelines for outpatient hysteroscopy, there are unresolved issues around adequate training and accreditation of future hysteroscopists. Virtual-reality simulation training for operative hysteroscopy has shown promising preliminary results, and it is being aggressively evaluated and validated. This review article is an attempt to provide a useful practical guide to all those who wish to implement ambulatory hysteroscopy services in their outpatient departments.

What is the role of hysteroscopic surgery in the management of female infertility? A review of the literature

The position of hysteroscopy in current fertility practice is under debate. There are many randomized controlled trials on technical feasibility and patient compliance demonstrating that the procedure is well tolerated and effective in the treatment of intrauterine pathologies. However, no consensus on the effectiveness of hysteroscopic surgery in improving the prognosis of subfertile women is available. A literature review was performed to explore the available information regarding the role of hysteroscopy in the evaluation and management of female infertility as well as to ascertain evidence that treatment of these uterine abnormalities improves fertility. The debate regarding the role of hysteroscopic surgery in the management of female infertility remains as the published studies did not reach a consensus on the benefit of such an intervention in this setting. The randomized trials do not clearly demonstrate that surgical correction of all intrauterine abnormalities improves IVF outcome. However, published observational studies suggest a benefit for resection of submucosal leiomyomas, adhesions, and endometrial polyps in increasing pregnancy rates. More randomised controlled studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected intrauterine pathology in women with unexplained subfertility or prior to assisted reproductive technology.

An audit of using the H Pipelle for endometrial sampling at outpatient hysteroscopy and literature review comparison with the Pipelle de Cornier

OBJECTIVE

To analyse the efficiency of the H Pipelle endometrial sampler at "no touch" (vaginoscopic) diagnostic hysteroscopy in terms of biopsy adequacy for histological diagnosis.

STUDY DESIGN

Retrospective descriptive study of 200 premenopausal women including comparison with previously published data on traditional biopsy instruments.

RESULTS

Biopsy was adequate in 82% of cases overall, rising to 87% in those without submucous fibroids or polyps. Comparison with published data on other biopsy instruments shows that the H Pipelle is at least as efficient.

CONCLUSION

The H Pipelle appears to be at least as effective as traditional endometrial samplers even after hysteroscopy but allows hysteroscopy and biopsy to be done using a purely "no touch" (vaginoscopic) technique.

Relationship between adenomyosis and uterine polyps

OBJECTIVE

To evaluate whether adenomyosis is associated with uterine polyps.

STUDY DESIGN

To perform an ethical human study, we planned a large retrospective observational study covering the entire patient population of the ULSS 17-Veneto district who underwent resectoscopy in 2007 and 2008 (959 patients). We enrolled all the patients underwent resectoscopy with resection of uterine polyps, with resection of myomas, with endometrial ablations by slicing, and with endometrial biopsies in both the presence and absence of hysteroscopically visible lesions. The diagnosis of adenomyosis was made by pathological examination of tissue specimens obtained using a resectoscope loop. Multivariate logistic regression was performed to determine if adenomyosis was one of the various risk factors for the presence and number of uterine polyps. Statistical Package for the Social Sciences (SPSS 16.0) was employed, and p≤0.05 was the minimum for significance.

RESULTS

Age (p=0.005), adenomyosis (p=0.013), high fasting glucose levels (p=0.004), and hypertension (p=0.045) were significantly associated with endometrial polyps. The presence of multiple endometrial polyps seemed to be associated with the presence of adenomyosis (p=0.016). The presence of cervical polyps was significantly associated only with presence of adenomyosis (p=0.002). The presence of multiple cervical polyps did not seem to be influenced by any of the variables considered.

CONCLUSIONS

The results clearly demonstrate an association between adenomyosis and uterine polyps. The pathogenetic role of adenomyosis in the development of polyps should therefore be investigated further.

Review of new office-based hysteroscopic procedures 2003-2009

Office operative hysteroscopy is a recent technique that enables treatment of uterine pathologic disorders in the ambulatory setting using miniaturized hysteroscopes with mechanical or electric instruments. The available international literature from 1990 to 2002 has clearly demonstrated that such technique enables performance of hysteroscopically directed endometrial biopsy and treatment of uterine adhesions, anatomic disorders, polyps, and small myomas safely and successfully without cervical dilation and the need for anesthesia. This review provides a comprehensive survey of further advancements of office operative hysteroscopy in the treatment of other gynecologic pathologic conditions that have not been included in the schema of treatment indications for office procedures proposed in 2002. A search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified articles published from 2003 to 2009. Eighteen articles were identified: 9 on hysteroscopic sterilization; 1 on office-based metroplasty, 8 on office-based treatment of some uncommon gynecologic pathologic conditions (e.g., hematometra, diagnosis and treatment of vaginal lesions, treatment of uterine cystic neoformations, bleeding from the cervical stump, diagnosis and treatment of endocervical ossification, and removal of uterovaginal packing). All performed procedures were carried out safely and successfully in the office setting, with high patient tolerance and minimal discomfort. The success of the procedures has been confirmed by resolution of symptoms and at follow-up ultrasonographic and hysteroscopic examinations. Currently, as a result of technologic advancements and increased operator experience, an increasing number of gynecologic pathologic conditions traditionally treated in the operating room may be treated safely and effectively using office operative hysteroscopy.

The nature of intrauterine adhesions following reproductive hysteroscopic surgery as determined by early and late follow-up hysteroscopy: clinical implications

OBJECTIVE

To evaluate the rate and characteristics of postoperative intrauterine adhesions (IUA) that might be formed following hysteroscopic reproductive surgery from both a gross and a histologic perspective as determined by early and late follow-up diagnostic hysteroscopy.

METHODS

Retrospective analysis of 61 women wishing a pregnancy and suffering from a significant intrauterine pathology affecting their reproductive outcome were reviewed. All patients were treated hysteroscopically. Subsequently, they were randomly assigned to perform a follow-up diagnostic hysteroscopy at a variable intervals from their initial surgery. Multiple hysteroscopic-guided biopsies from IUA, when present, were obtained in several cases. Twenty patients were in the early group and had follow-up hysteroscopy performed 2-4 weeks after the initial operation. The late diagnostic group consisted of 41 patients with follow-up hysteroscopy at about 12 months (8-16 months). The two groups were similar to composition. Postoperatively, none of the early diagnostic group underwent hysterosalpingography (HSG) whereas all of the late group performed HSG 4 months following the initial surgery, which showed at least one-third of the cavity free of adhesions. When adhesions were present, no effort was made to lyse them.

RESULTS

At follow-up hysteroscopy, 25% of both groups had no significant adhesions. Grade I adhesions (thin, filmy) occurred in 60% of the early hysteroscopy patients and in only 12% of the late group (P < 0.05). Grade II adhesions were present in 10% of the early group and in up to 41% in the late group (P < 0.05), whereas Grade III adhesions were present in only 5% of the early hysteroscopy group, but in 22% of the late one (P < 0.05). Correlation between hysteroscopic and histologic findings were good in most of cases in both groups. Follow-up to determine the subsequent reproductive outcome revealed similar conception rates in both groups.

CONCLUSION

The IUA that might be formed immediately following hysteroscopic reproductive surgery are histologically different from those appearing a longer time after the original operation. Routine early follow-up hysteroscopy can influence the prognosis resulting from the original surgery.

Ambulatory hysteroscopy: evidence-based guide to diagnosis and therapy

Healthcare providers are facing increasing demands for improvement in quality of life for patients. Improvements in service provision for women are being ensured by the introduction of minimally invasive technologies into all spheres of gynaecologic practice. Ambulatory hysteroscopy (direct endoscopic visualization of the endometrial cavity) is an extremely exciting and rapidly advancing field of gynaecologic practice. It advanced dramatically during the 1990s, shifting the focus in healthcare away from inpatient diagnosis and treatment. Hysteroscopy is used extensively in the evaluation of common gynaecological problems that were previously evaluated with blind and inaccurate techniques (e.g. premenopausal menstrual disorders, infertility and postmenopausal bleeding). It allows direct visualization of the uterine cavity and the opportunity for targeted biopsy, safe removal of endometrial polyps, and treatment of submucous fibroids, septa and adhesions. Ambulatory hysteroscopy is safe, with a low incidence of serious complications; it has a small failure rate. There is a general consensus that hysteroscopy is the current gold standard for evaluating intrauterine pathology, including submucous myomas, polyps, hyperplasia and cancer. Hysteroscopy in the ambulatory setting appears to have an accuracy and patient acceptability equivalent to inpatient hysteroscopy under general anaesthetic. The primary goal of this chapter is to provide a high-quality, evidence-based text on ambulatory diagnostic and operative hysteroscopy. The chapter includes in-depth analysis of the indications for outpatient hysteroscopy, its contraindications, the accuracy of diagnostic hysteroscopy, relevant risk management issues and, training and teaching.