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van der Meulen JF, Bongers MY, van der Zee LG, Leemans JC, Duijnhoven RG, de Leeuw RA, Overdijk LE, Radder CM, van der Voet LF, Smeets NAC, van Vliet HAAM, Hehenkamp WJK, Manger AP, Lim AC, Peters LW, Horree N, Briët JM, van der Steeg JW, Coppus SFPJ, Kok HS. Procedural sedation and analgesia versus general anesthesia for hysteroscopic myomectomy (PROSECCO trial): A multicenter randomized controlled trial. PLoS Med 2023; 20:e1004323. [PMID: 38153958 PMCID: PMC10754450 DOI: 10.1371/journal.pmed.1004323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 11/15/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND Hysteroscopic resection is the first-choice treatment for symptomatic type 0 and 1 fibroids. Traditionally, this was performed under general anesthesia. Over the last decade, surgical procedures are increasingly being performed in an outpatient setting under procedural sedation and analgesia. However, studies evaluating safety and effectiveness of hysteroscopic myomectomy under procedural sedation are lacking. This study aims to investigate whether hysteroscopic myomectomy under procedural sedation and analgesia with propofol is noninferior to hysteroscopic myomectomy under general anesthesia. METHODS AND FINDINGS This was a multicenter, randomized controlled noninferiority trial conducted in 14 university and teaching hospitals in the Netherlands between 2016 and 2021. Inclusion criteria were age ≥18 years, maximum number of 3 type 0 or 1 fibroids, maximum fibroid diameter 3.5 cm, American Society of Anesthesiologists class 1 or 2, and having sufficient knowledge of the Dutch or English language. Women with clotting disorders or with severe anemia (Hb < 5.0 mmol/L) were excluded. Women were randomized using block randomization with variable block sizes of 2, 4, and 6, between hysteroscopic myomectomy under procedural sedation and analgesia (PSA) with propofol or under general anesthesia (GA). Primary outcome was the percentage of complete resections, assessed on transvaginal ultrasonography 6 weeks postoperatively by a sonographer blinded for the treatment arm and surgical outcome. Secondary outcomes were the surgeon's judgment of completeness of procedure, menstrual blood loss, uterine fibroid related and general quality of life, pain, recovery, hospitalization, complications, and surgical reinterventions. Follow-up period was 1 year. The risk difference between both treatment arms was estimated, and a Farrington-Manning test was used to determine the p-value for noninferiority (noninferiority margin 7.5% of incomplete resections). Data were analyzed according to the intention-to-treat principle, including a per-protocol analysis for the primary outcome. A total of 209 women participated in the study and underwent hysteroscopic myomectomy with PSA (n = 106) or GA (n = 103). Mean age was 45.1 [SD 6.4] years in the PSA group versus 45.0 [7.7] years in the GA group. For 98/106 women in the PSA group and 89/103 women in the GA group, data were available for analysis of the primary outcome. Hysteroscopic resection was complete in 86/98 women (87.8%) in the PSA group and 79/89 women (88.8%) in the GA group (risk difference -1.01%; 95% confidence interval (CI) -10.36 to 8.34; noninferiority, P = 0.09). No serious anesthesiologic complications occurred, and conversion from PSA to GA was not required. During the follow-up period, 15 serious adverse events occurred (overnight admissions). All were unrelated to the intervention studied. Main limitations were the choice of primary outcome and the fact that our study proved to be underpowered. CONCLUSIONS Noninferiority of PSA for completeness of resection was not shown, though there were no significant differences in clinical outcomes and quality of life. In this study, hysteroscopic myomectomy for type 0 and 1 fibroids with PSA compared to GA was safe and led to shorter hospitalization. These results can be used for counseling patients by gynecologists and anesthesiologists. Based on these findings, we suggest that hysteroscopic myomectomies can be performed under PSA in an outpatient setting. TRIAL REGISTRATION The study was registered prospectively in the Dutch Trial Register (NTR 5357; registration date: 11 August 2015; Date of initial participant enrollment: 18 February 2016).
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Affiliation(s)
- Julia F. van der Meulen
- Department of Obstetrics & Gynecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Grow school for oncology and reproduction, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marlies Y. Bongers
- Department of Obstetrics & Gynecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Grow school for oncology and reproduction, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lisa G. van der Zee
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Jaklien C. Leemans
- Department of Obstetrics & Gynecology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Ruben G. Duijnhoven
- Department of Obstetrics & Gynecology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
- Clinical Trials Unit, Netherlands Society for Obstetrics and Gynecology, Amsterdam, the Netherlands
| | - Robert A. de Leeuw
- Department of Obstetrics & Gynecology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | | | - Celine M. Radder
- Department of Obstetrics & Gynecology, OLVG, Amsterdam, the Netherlands
| | - Lucet F. van der Voet
- Department of Obstetrics & Gynecology, Deventer Ziekenhuis, Deventer, the Netherlands
| | - Nicol A. C. Smeets
- Department of Obstetrics & Gynecology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - Huib A. A. M. van Vliet
- Department of Obstetrics & Gynecology, Catharina Ziekenhuis, Eindhoven, the Netherlands
- Department of human structure and repair, Ghent University, Gent, Belgium
| | - Wouter J. K. Hehenkamp
- Department of Obstetrics & Gynecology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Arentje P. Manger
- Department of Obstetrics & Gynecology, Diakonessenhuis, Utrecht, the Netherlands
| | - Arianne C. Lim
- Department of Obstetrics & Gynecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Nicole Horree
- Department of Obstetrics & Gynecology, Flevoziekenhuis, Almere, the Netherlands
| | - Justine M. Briët
- Department of Obstetrics & Gynecology, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - Jan Willem van der Steeg
- Department of Obstetrics & Gynecology, Jeroen Bosch Ziekenhuis, ‘s-Hertogenbosch, the Netherlands
| | - Sjors F. P. J. Coppus
- Department of Obstetrics & Gynecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Department of Obstetrics & Gynecology, University Medical Centre St Radboud, Nijmegen, the Netherlands
| | - Helen S. Kok
- Department of Obstetrics & Gynecology, Alrijne Ziekenhuis, Leiden, the Netherlands
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Huang L, Yu Q, Zhu Z, Huang P, Ding X, Ma X, Chen Y, Su D. The Current Situation of Anaesthesia for Hysteroscopy in Mainland China: A National Survey. J Pers Med 2023; 13:1436. [PMID: 37888047 PMCID: PMC10608545 DOI: 10.3390/jpm13101436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/18/2023] [Accepted: 09/23/2023] [Indexed: 10/28/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Diansan Su
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China; (L.H.); (Q.Y.); (Z.Z.); (P.H.); (X.D.); (X.M.); (Y.C.)
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van der Meulen JF, Fisch C, Dreessen JRJ, Coppus SFPJ, Kok HS, Bongers MY. Procedural sedation and analgesia with propofol (PSA) for gynecologic surgery: A systematic review of the literature. Eur J Obstet Gynecol Reprod Biol 2023; 287:137-146. [PMID: 37327552 DOI: 10.1016/j.ejogrb.2023.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/03/2023] [Accepted: 05/25/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To identify which gynecologic procedures are eligible to be performed under PSA with propofol and to describe safety and effectiveness of these procedures in this setting. METHODS A systematic review of the literature was conducted in Pubmed (MEDLINE), Embase and The Cochrane Library from inception until September 21st 2022. Cohort studies and randomized controlled trials were included when they reported on clinical outcomes of gynecologic procedures under procedural sedation and analgesia in which propofol was used as an anesthetic. Studies were excluded when sedation without propofol was used, when they only mentioned the use of procedural sedation and analgesia but did not describe any clinical outcome parameters or when < 10 patients were included. The primary outcome parameter was completeness of procedure. Secondary outcome parameters were type of gynecologic procedure, intraoperative complication rate, patient satisfaction, postoperative pain, duration of hospital admission, patient's discomfort and ease of procedure as judged by the surgeon. The Cochrane risk of bias tool and the ROBINS-I tool were used for bias assessment. A narrative synthesis of the findings from the included studies was provided. Numbers and percentages were presented, as well as means with standard deviations and medians with interquartile range where applicable. RESULTS Eight studies were included. A total of 914 patients underwent gynecologic surgical procedures with procedural sedation and analgesia with propofol. Gynecological procedures varied from hysteroscopic procedures, vaginal prolapse surgery and laparoscopic procedures. The percentage of complete procedures was 89.8%-100%. Complications occurred in 0-6.5% of patients. Other outcomes were measured in various ways, but overall patient satisfaction was high and postoperative pain was low. CONCLUSION The use of PSA with propofol is promising for a wide range of gynecologic procedures, including hysteroscopic procedures, vaginal prolapse surgery and laparoscopic procedures. The use of PSA with propofol seems to be effective and safe and leads to high degree of patient satisfaction. More research is needed in order to determine for which types of procedures PSA can be used.
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Affiliation(s)
- Julia F van der Meulen
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, The Netherlands; Grow School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands.
| | - Charlotte Fisch
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, The Netherlands; Department of Obstetrics and Gynecology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Janique R J Dreessen
- Department of Obstetrics and Gynecology, Zuyderland Medical Centre, Heerlen, The Netherlands.
| | - Sjors F P J Coppus
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, The Netherlands.
| | - Helen S Kok
- Department of Obstetrics & Gynecology, Alrijne Ziekenhuis, Leiden, The Netherlands.
| | - Marlies Y Bongers
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, The Netherlands; Grow School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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Teaming in the ambulatory surgical space and crisis management strategies. Fertil Steril 2021; 117:22-26. [PMID: 34809973 DOI: 10.1016/j.fertnstert.2021.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/20/2022]
Abstract
Outpatient procedures and flexible staffing models have become prevalent within the ambulatory surgical and procedural spaces of reproductive endocrinology and infertility practice. High volumes of outpatients are treated daily by rotating nurses, surgeons, and anesthesia staff, often with the added layer of trainees present. "Teaming" can allow stable units and ad hoc groups to partner better for enhanced efficiency, effectiveness, and patient experience in routine procedural activities. These skills then can be parlayed into the rare moments of crisis to improve safety outcomes. Teaming concepts, applied in routine and acute scenarios, can optimize clinical operations, patient experience, and outcomes in our reproductive endocrinology and infertility ambulatory procedural and surgical spaces.
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