Hysteroscopy: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

A cost-effectiveness analysis of intrauterine spacers used to prevent the formation of intrauterine adhesions following endometrial cavity surgery

AIM

To assess, from a United States (US) payer's perspective, the cost-effectiveness of gels designed to separate the endometrial surfaces (intrauterine spacers) placed following intrauterine surgery.

MATERIALS AND METHODS

A decision tree model was developed to estimate the cost-effectiveness of intrauterine spacers used to facilitate endometrial repair and prevent the formation (primary prevention) and reformation (secondary prevention) of intrauterine adhesions (IUAs) and associated pregnancy- and birth-related adverse outcomes. Event rates and costs were extrapolated from data available in the existing literature. Sensitivity analyses were conducted to corroborate the base case results.

RESULTS

In this model, using intrauterine spacers for adhesion prevention led to net cost savings for US payers of $2,905 per patient over a 3.5-year time horizon. These savings were driven by the direct benefit of preventing procedures associated with IUA formation ($2,162 net savings) and the indirect benefit of preventing pregnancy-related complications often associated with IUA formation ($3,002). These factors offset the incremental cost of intrauterine spacer use of $1,539 based on an assumed price of $1,800 and the related increase in normal deliveries of $931. Model outcomes were sensitive to the probability of preterm and normal deliveries. Budget impact analyses show overall cost savings of $19.96 per initial member within a US healthcare plan, translating to $20 million over a 5-year time horizon for a one-million-member plan.

LIMITATIONS

There are no available data on the effects of intrauterine spacers or IUAs on patients' quality of life. Resultingly, the model could not evaluate patients' utility related to treatment with or without intrauterine spacers and instead focused on costs and events avoided.

CONCLUSION

This analysis robustly demonstrated that intrauterine spacers would be cost-saving to healthcare payers, including both per-patient and per-plan member, through a reduction in IUAs and improvements to patients' pregnancy-related outcomes.

Does vaginal cleansing with iodine decreases infection rate in office hysteroscopy?

PURPOSE

To determine whether preoperative vaginal cleansing with iodine-based solution prior to hysteroscopy, reduces postoperative infection rate compared to no vaginal cleansing.

METHODS

A retrospective study at a single tertiary, university affiliated hospital of all individuals who have had an office hysteroscopy. Study group consisted of patients who have had preoperative vaginal cleansing with iodine-based solution and were compared to those who have not. Any procedural related complaints at the 30 days following the hysteroscopy were recorded.

RESULTS

A total of 505 were available for analysis, 183 in the study group and 322 in the control group. The most common indications for operation were infertility evaluation (33.9% vs. 28.6%) and retained products of conception (33.3% vs. 29.2%), and most common procedures were diagnostic only (49.7% vs. 42.5%) followed by adhesiolysis (12% vs. 14.3%). No statistical differences were noted with regards to postoperative infections, as only one case of pelvic inflammatory disease was noted, in the iodine cleansing group (0.19% for postoperative infection).

CONCLUSION

Our comparative study may suggest that the use of preoperative iodine solution prior to office hysteroscopy does not decrease the postoperative infection rate up to 30 days, thus can be avoided.

The Current Situation of Anaesthesia for Hysteroscopy in Mainland China: A National Survey

Purpose: The need for anaesthesia or analgesia for performing hysteroscopy remains debatable. This study aimed to conduct an overview of the situation of anaesthesia for hysteroscopy in mainland China. Methods: Two questionnaires were separately designed for anaesthesiologists and gynaecologists and distributed to every medical institution that performed hysteroscopic procedures on patients with infertility in mainland China. Electronic questionnaires were distributed via WeChat, and data on anaesthesia regimen, monitoring parameters, procedure number, and other information were collected. Results: Reproductive technology is conducted by 536 institutions in mainland China. The survey received 491 responses from anaesthetists (91.6%) and 436 from gynaecologists (81.3%). In 2021, 552,225 hysteroscopies were conducted in 268 medical centres. The average percentage of hysteroscopy under anaesthesia is 63.8% in 2021, wherein 47.3% of institutions have an anaesthesia percentage of >75%. Propofol and opioid analgesics, such as fentanyl and sufentanil, were the most commonly used intravenous anaesthetics. All sedations were performed by anaesthesiologists. Monitoring parameters included pulse oxygen saturation (98.9%), electrocardiogram (91.6%) and noninvasive blood pressure (91.3%). An anaesthesiologist-to-operating room ratio of <1 was observed in 31.3% of medical institutions. Surprisingly, 52.4% of medical institutions performing hysteroscopy had no postanaesthesia care unit (PACU). Most institutions with PACU were equipped with independent oxygen sources, suction and monitors. Both rigid and flexible hysteroscopes (rigid hysteroscope, 45.1%; flexible hysteroscope, 4.5%; both types, 50.4%) were used, and the hysteroscopic diameter was ≤5 mm in 60.3% of medical centres. Conclusions: China performs a large number of hysteroscopies, and sedation is the most frequently used anesthesia regimen. However, issues such as inadequate emergency support devices, insufficient personnel and weak resuscitation management after anaesthesia, have been observed.

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.

Clinical Issues - March 2023

Conversion to an open procedure Key words: laparoscopic procedure, open procedure, emergent conversion, open procedure cart, preoperative briefing. Excess absorption of fluid distension media Key words: fluid distension media, arthroscopy, transurethral resection (TUR) syndrome, fluid extravasation, fluid intravasation. Hysteroscopic fluid deficit thresholds Key words: maximum fluid deficit, hysteroscopy, hypotonic solution, isotonic solution, distension media. Alternative insufflation gases Key words: carbon dioxide (CO2 ), nitrous oxide (N2 O), insufflation, gas distension media, pneumoperitoneum.

Hysteroscopy for retained products of conception: a single-institution experience

BACKGROUND

Retained products of conception can occur with induced abortion during early-term pregnancy, induction of labor during mid-term pregnancy, drug-induced abortion, miscarriage, cesarean delivery, or full-term normal delivery. Compared with traditional dilation and curettage, hysteroscopy is a safer and more effective treatment method for retained products of conception. This study aimed to report the efficacy of hysteroscopy for treating retained products of conception and to share our new clinical perspectives.

METHODS

This retrospective, single-center study was conducted at a tertiary hospital in Chengdu, China. We included 36 patients with retained products of conception who underwent hysteroscopy at our hospital.

RESULTS

Our study reported a complete removal rate of 80.5% (29/36) with one procedure. The normal menstruation recovery rate during 1 year of follow-up was 91.6% (33/36). A low rate of postoperative intrauterine adhesions (2.8% [1/36]) was also reported.

CONCLUSION

Our retrospective study elucidated the use of hysteroscopy for retained products of conception. We also shared new perspectives regarding hysteroscopy and optimal surgical methods for treating retained products of conception as well as our experience treating residual products with hysteroscopy. To our knowledge, no other study has shared similar experiences.

High-flow nasal oxygen reduces the incidence of hypoxia in sedated hysteroscopy for assisted reproduction

Backgrounds and aims

Pain is the main reason for hysteroscopy failure. In day-surgical settings, hysteroscopy procedures are commonly performed with the patient under sedation. Hypoxia is the most common adverse event during sedation and can lead to severe adverse events. This study aimed to compare the incidence of hypoxia when using high-flow nasal oxygen (HFNO) with that when using regular nasal oxygen in patients undergoing hysteroscopy with sedation.

Materials and methods

In this single-center, prospective, randomized, single-blinded study, 960 female patients undergoing elective diagnostic or operative hysteroscopy were randomly enrolled into the following two groups: the regular nasal group [O₂ (3–6 L/min) covered by an HFNO] and the HFNO group [O₂ (30–60 L/min)] from September 2021 to December 2021. All women were sedated with propofol (1.5 mg/kg) and remifentanil (1.5 μg/kg) in the operating room. The primary outcome was the incidence of hypoxia (75% ≤ SpO₂ < 90%, < 60 s).

Results

HFNO decreased the incidence of hypoxia (75% ≤ SpO₂ < 90%, < 60 s), subclinical respiratory depression (90% ≤ SpO₂ < 95%) and severe hypoxia (SpO₂ < 75% for any duration or 75% ≤ SpO₂ < 90% for ≥ 60 s) from 24.38 to 0.83%, from 11.25 to 1.46% and from 3.75 to 0%, respectively (P < 0.001).

Conclusion

In procedures conducted to treat female infertility, HFNO can reduce hypoxia during hysteroscopy in patients sedated with propofol, and it can prevent the occurrence of subclinical respiratory depression and severe hypoxia.

Comparison between Different Diagnostic Strategies in Low-Risk Reproductive Age and Pre-Menopausal Women Presenting Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is a common symptom in the female population, with an estimated prevalence of 10 to 30% in fertile age and up to 90% in perimenopausal women. In most cases, AUB is due to a benign cause. However, it can also be a symptom of atypical endometrial hyperplasia or endometrial cancer, a more common disease during menopause which can also affect women in their reproductive age. Considering the high prevalence of this symptom an appropriate diagnostic algorithm is needed. Concerns about the risks, pain, and stress associated with an endometrial biopsy and its impact on the healthcare system make the choice of AUB diagnostic strategy extremely relevant. Even if the scientific community agrees on the definition of AUB, International Guidelines show some differences in the management of women of reproductive age with AUB, especially regarding the age cut-off as an independent indication for endometrial biopsy. This study compared different diagnostic strategies to identify a diagnostic pathway with high sensitivity and specificity but low impact on the health system's resources. The analysis was based on three diagnostic algorithms defined as part of the guidelines of leading scientific societies. Women of reproductive age with AUB (n = 625) and without risk of endometrial cancer were included in the study. Results showed that the best criterion to investigate AUB in women at low risk of endometrial cancer is not age cut-off but the presence or absence of focal endometrial pathology at the ultrasound and the response to the progestin therapy. This approach makes it possible to perform fewer outpatient hysteroscopic biopsies without excluding positive cases from the examination.

The effect of preoperative intravenous lidocaine on postoperative pain following hysteroscopy: A randomized controlled trial

BACKGROUND

The use of hysteroscopy for the diagnosis and treatment of uterine and endometrial abnormalities is often associated with postoperative pain. This randomized controlled trial aimed to assess the efficacy of preoperative intravenous (IV) lidocaine in reducing pain after hysteroscopy.

METHODS

In total, 138 patients undergoing elective hysteroscopy at the CHA Bundang Medical Center, Seongnam, Korea were randomly assigned to a control group (n = 69) or a lidocaine group (n = 69), which received normal saline or IV lidocaine at 1.5 mg/kg, respectively. The primary outcome was the incidence of postoperative pain.

RESULTS

The incidence of pain was significantly lower in the IV lidocaine group than in the control group at the post-anesthesia care unit (27.3% vs 68.2%, P < .001). The visual analog scale (0-10) score (median [interquartile range]) was lower in the IV lidocaine group than in the control group (0 [0-2]) vs 2 [0-4]), P < .001). The use of rescue analgesics and postoperative nausea and vomiting were similar between the 2 groups. This study demonstrated that administering 1.5 mg/kg of preoperative IV lidocaine can be a simple method to reduce incidence of pain after hysteroscopy.

CONCLUSION

Preoperative bolus administration of 1.5 mg/kg of IV lidocaine may be used to decrease incidence of pain after hysteroscopy under general anesthesia.

Can we rely on blind endometrial curettage for complete removal of focal intrauterine lesion? A prospective clinical study

OBJECTIVE

To investigate the diagnostic and therapeutic efficiency of dilatation-curettage (D&C) combined with aspiration curettage for endometrial pathology compared to hysteroscopy alone in this study.

MATERIAL AND METHODS

A total of 143 patients who have suspicion of endometrial mass like lesion, increased endometrial thickness (>5-mm at menopause and/or endometrial thickness upper than 5-mm in patients under tamoxifen treatment due to breast cancer during 2-D transvaginal ultrasonography examination) were enrolled. All patients underwent procedures in order of hysteroscopy, D&C plus aspiration and second look hysteroscopy. Data for age, menopausal status, tamoxifen treatment, endometrial histology, hysteroscopy and D&C findings were recorded and statistically analyzed.

RESULTS

Initial hysteroscopy revealed focally growing endometrial lesion in 96 patients. Second look hysteroscopy showed persistent focal lesion in 77 patients (80 %) after D&C plus aspiration. Endometrial blind curettage failed to diagnose 42 % (25/60) of endometrial polyps, none of submucous myomas as well as 27 % (3/11) of premalignant and malignant endometrial lesions. The sensitivity, specificity, overall accuracy, positive predictive value and negative predictive value of hysteroscopy were found as 84.1 %, 83.3 %, 83.9 %, 93.8 %, and 63.8 %, respectively.

CONCLUSIONS

Hysteroscopy showed significant superiority in the diagnosis and definitive treatment of endometrial pathologies specifically in focally growing endometrial lesions compared to D&C plus aspiration.

Operative hysteroscopy for retained products of conception: Efficacy and subsequent fertility

Retained product of conception complicates nearly 1% of pregnancies and can lead to synechiae and compromise ulterior fertility. The aim of this study is to evaluate efficiency of operative hysteroscopy in management of retained products of conception (RPOC). Secondary objectives are assessments of intra-uterine adhesions rate and later fertility. This unicentric retrospective study includes women who undertook an operative hysteroscopy for retained products of conception between January 2012 and March 2014. Assessment of the efficiency of operative hysteroscopy is defined by a complete resection of retained products of conception confirmed by office hysteroscopy. One hundred fourteen women were included in the study. Efficiency of operative hysteroscopy for retained products of conception is 91% for women with a postoperative office hysteroscopy. The authors observed a 7.5% rate of postoperative intra-uterine adhesions. Fertility rate was 83% (30 women out of 36 with a desired pregnancy). Hysteroscopic resection of retained products of conception is an efficient procedure and seems to be a real alternative.

Predicting success of single step hysteroscopic myomectomy: A single centre large cohort study of single myomas

INTRODUCTION

Submucous myomas represent one of the main indications of operative hysteroscopy. Hysteroscopic resection of submucous fibroids should be a simple, well-tolerated and effective procedure and ideally accomplished in in only one surgical step.

METHODS

Retrospective cohort single Centre study of 1244 women undergoing hysteroscopic myomectomy. Data analysis included patients' and the myomas characteristics. A multiple logistic regression was carried out in order to assess which variables were able to determine a multiple step procedure.

RESULTS

1090 myomas (87.62%) were completely resected in a single-step procedure (SS group) whereas a multiple-step procedure (MS group) was needed for the removal of 154 fibroids (12.38%). The mean size of myomas resected in the SS group was 22.83 ± 9.36 mm whereas fibroids of the MS group measured 29.67 ± 10.76 mm. The overall feasibility of hysteroscopic myomectomy in one surgical procedure was 88.28%. All hysteroscopic myomectomies of G0 fibroids were completed in a single step. The chance of success to accomplish the treatment in a single-step for G1 and G2 myomas were 88.59% and 82.55%, respectively. The multivariate analysis revealed an inverse correlation between age and multiple step procedures and size of myomas were all directly correlated to multiple step procedures.

CONCLUSION

The grading, the size of the myomas and the age of patients play a crucial role in completing the hysteroscopic myomectomy in a single step. Only the diameter greater than 3 cm in G2 myomas is correlated to a higher risk of a multiple procedure.

Influence of auto-cross-linked hyaluronic acid gel on pregnancy rate and hysteroscopic outcomes following surgical removal of intra-uterine adhesions

OBJECTIVE

To determine the effect of the use of auto-cross-linked hyaluronic acid (ACP) gel following hysteroscopic surgery on the prevention of intra-uterine adhesions (IUAs) and the pregnancy rate.

STUDY DESIGN

An observational retrospective study of 90 patients who underwent hysteroscopic removal of IUAs was conducted between 2008 and 2013 at a tertiary university care centre. Thirty-two patients received ACP gel during hysteroscopic removal of IUAs, and the remaining 58 patients did not receive ACP gel. Controls were matched to cases according to infertility and severity of IUAs using the American Society for Reproductive Medicine (ASRM) score. Four to six weeks after surgery, patients underwent diagnostic hysteroscopy to determine the re-occurrence of IUAs or the presence of adhesions. The patients were contacted by telephone to answer a questionnaire concerning their fertility. The main outcomes were pregnancy rate and postoperative IUAs.

RESULTS

Pregnancy (viable or not) rates were not influenced by the use of ACP gel. The viable pregnancy rate was eight of 24 (33.3%) in the ACP gel group and 12 of 49 (24.5%) in the control group (p=0.427). The mean interval between surgery and pregnancy was 11.8 [standard deviation (SD) 10.5] months in the ACP group compared with 13.4 (SD 14.1) months in the control group (p=0.744). The mean ASRM score after surgery (hysteroscopic diagnosis at 4-6 weeks postoperatively) was equivalent in the two groups: 2.7 (SD 3.0) in the ACP gel group vs 2.6 (SD 3.2) in the control group (p=0.854). The mean follow-up was 45.2 months (interquartile range 33.2-52.7), with a loss to follow-up of 25% in the ACP gel group compared with 15.5% in the control group (p=0.817).

CONCLUSION

Application of ACP gel did not prevent recurrence of IUAs and was not associated with an increased pregnancy rate. ACP gel should be used with caution pending assessment in a randomized control trial in a larger population.

Safety and efficacy of manual syringe infusion of distending media for hysteroscopic procedures: a case-control study

OBJECTIVES

Adverse events associated with large volumes of distending media in hysteroscopic procedures can be life-threatening. The aim of this study was to evaluate the safety and efficacy of manual syringe infusion (MI) of distending media for hysteroscopic procedures.

STUDY DESIGN

Between January 2011 and December 2013, the medical records of all women who underwent hysteroscopic procedures using MI or the conventional pump-infusion method (PI, the control group) were reviewed. The Wilcoxon rank-sum test, the Chi-square test and the multivariate logistic regression analysis were employed for statistical analysis.

RESULTS

The MI group (n=82) had a significantly lower average volume of infused fluid (1117 ± 712 mL vs. 2216 ± 1502 mL, respectively; p<0.001), less operative time (22.2 ± 9.7 vs. 30.4 ± 9.8 min, respectively; p<0.001) and lower postoperative abdominal pain scores (0.6 ± 0.7 vs. 0.8 ± 0.7, respectively; p=0.04) than the PI group (n=58). Subgroup analysis of women who underwent hysteroscopic myomectomy revealed a significantly lower amount of infused fluid for the MI group than for the PI group (1737 ± 905 mL vs. 3441 ± 1952 mL, respectively; p=0.001). Infused fluid amount (coefficient=0.08, p<0.001) was the only significant independent factor affecting fluid deficit, with a constant of 76.1.

CONCLUSION

The MI method appears to be a safe and feasible method for delivering distending media during hysteroscopic procedures.

[Operative hysteroscopy for myoma removal: Morcellation versus bipolar loop resection]

OBJECTIVE

To evaluate the results associated with hysteroscopic morcellation for submucous myomas removal, and to compare with those observed associated with bipolar loop resection.

MATERIELS AND METHODS

A retrospective comparative study was conducted in two universitary centers from January 2012 to December 2013. A total of 83 patients, who presented with submucous myomas type 0,1 and 2, were included. The number of myomas type 0,1 was 36 (71 %) and 15 (29 %) myomas type 2 in morcellation group versus 44 (59 %) myomas type 0,1 and 31 (41 %) type 2 in electrosurgical resection group (P=0.17). Hysteroscopic morcellation or electrosurgical resection with bipolar loop for removal submucous myomas were performed.

RESULTS

Thirty-four patients underwent hysteroscopic morcellation using MyoSure(®), and 49 had hysteroscopic resection using Versapoint-24F(®) bipolar loop. The mean operative duration was 30minutes in morcellation group, compared to 31minutes in bipolar resection group (P=0.98). Complete myoma removal was achieved in 22 (64 %) patients in morcellation group, and in 34 (69 %) in bipolar resection group (P=0.65). There were no difference in the occuring of adverse events between the two. The prevalence of postoperative intra-uterine adherence was 10 % in morcellation group and 13.8 % in bipolar resection group (P=0.69).

CONCLUSION

In the current short comparative series, hysteroscopic morcellation and bipolar loop resection were associated with comparable results for removal of submucous myomas.