Feasibility of Resectoscopic Operative Hysteroscopy in a UK Outpatient Clinic Using Local Anesthetic and Traditional Reusable Equipment, With Patient Experiences and Comparative Cost Analysis

Safety and Efficiency Outcomes of Ambulatory Gynaecologic Procedures in Canadian Surgical Centres Adopting a Common Model

OBJECTIVE

The present study aims to compare the safety and efficiency outcomes of ambulatory gynaecologic procedures performed under conscious sedation and/or local anaesthetic at 2 Canadian institutions.

METHODS

A retrospective cohort study was completed over 1-year on patients presenting to the ambulatory care centres at 2 Canadian institutions that shared a common care model. Outcomes of interest were lead time (registration to discharge), procedural time, and intraoperative complications. Surgical data was derived from a retrospective chart review and outcomes were compared using the independent t test and one-way analysis of variance.

RESULTS

A total of 1495 and 1098 patients presented to the 2 sites. The average age of patients was 35.5 ± 12.3 years and 41.7 ± 10.2 years. The most commonly performed procedures were dilatation and curettages at the first centre and operative hysteroscopies at the second centre. Average lead times were similar: 170.3 ± 35.8 minutes and 171.6 ± 45.4 minutes (P = 0.45). There was a significant difference in mean procedural time being 9.8 ± 5.5 minutes and 17.0 ± 10.0 minutes (P < 0.001). The rate of minor intraoperative complications was 3.8% and 6.6% (P = 0.002); whereas the rate of major complications was 2.7% and 3.3% (P = 0.43).

CONCLUSION

In Canada, the majority of gynaecologic procedures are performed under general anesthesia. By comparing outcomes at 2 separate Canadian centres, we demonstrated the reproducibility of a common ambulatory model for minor gynaecologic procedures, supporting the implementation of similar care models across Canada.

Perioperative costs of local or regional anesthesia versus general anesthesia in the outpatient setting: a systematic review of recent literature

BACKGROUND AND OBJECTIVES

In this systematic review, we carried out an assessment of perioperative costs of local or regional anesthesia versus general anesthesia in the ambulatory setting.

METHODS

A systematic literature search was conducted to find relevant data on costs and cost-effectiveness analyses of anesthesia regimens in outpatients, regardless of the medical procedure they underwent. The hypothesis was that local or regional anesthesia has a lower economic impact on hospital costs in the outpatient setting. The primary outcome was the average total cost of anesthesia calculated on perioperative costs (drugs, staff, resources used).

RESULTS

One-thousand-six-hundred-ninety-eight records were retrieved, and 28 articles including 27,581 patients were selected after reviewing the articles. Data on the average total costs of anesthesia and other secondary outcomes (anesthesia time, recovery time, time to home readiness, hospital stay time, complications) were retrieved. Taken together, these findings indicated that local or regional anesthesia is associated with lower average total hospital costs than general anesthesia when performed in the ambulatory setting. Reductions in operating room time and postanesthesia recovery time and a lower hospital stay time may account for this result.

CONCLUSIONS

Despite the limitations of this systematic review, mainly the heterogeneity of the studies and the lack of cost-effectiveness analysis, the economic impact of the anesthesia regimes on healthcare costs appears to be relevant and should be further evaluated.

Four year evaluation of therapeutic hysteroscopy under procedural sedation in an outpatient clinic

OBJECTIVE

Due to the evolution of hysteroscopic instruments, therapeutic hysteroscopic procedures are increasingly performed in an outpatient, office-based setting. The most important limiting factor of performing these hysteroscopic treatments is patient discomfort. Procedural Sedation Analgesia (PSA) decreases patient discomfort and anxiety. The main goal of this study is to determine safety, feasibility and patient satisfaction of therapeutic hysteroscopy performed under procedural sedation in an outpatient clinic. Our second objective was to compare 9 mm scopes with smaller diameter scopes.

STUDY DESIGN

All consecutive patients suitable for procedural sedation and scheduled for a therapeutic hysteroscopy in the outpatient clinic were prospectively included from February 2014 to November 2018 in a teaching hospital in the Netherlands. A variety of therapeutic hysteroscopies procedures was performed including myomectomy, removal of retained products of conception and endometrial ablation. Therapeutic hysteroscopes with 3.8 mm, 5 mm and 9 mm diameter were used. In all selected women procedure time, admission time, pain scores, anaesthesiologic and procedural complications were assessed. All women received a questionnaire on patient satisfaction.

RESULTS

In total 455 patients underwent a therapeutic hysteroscopy. Median procedure time was 11 min (2-63 min) and median admission time was 130 min (30-480 min). Median pain score according to the visual analog scale (VAS) before, during and after procedure were respectively 0 (0-10), 0 (0-4) and 0 (0-9). Anaesthesiologic complication rate was 4.4 %, all minor. Procedural complications consisted of infection postoperatively (0.4 %), excessive blood loss during procedure (0.6 %) and perforation (0.4 %). Procedure was incomplete in 3.3 % of all procedures. Patient satisfaction was high, as 96 % of the women were satisfied. No differences were found in pain scores, VAS 0 versus 1 after the procedure, between 3.8 or 5 mm and 9 mm scopes.

CONCLUSION

It is safe and feasible to perform a therapeutic hysteroscopy under procedural sedation in an outpatient setting, with low pain scores and a high degree of patient satisfaction, also when large diameter instruments are used.

Patient and provider satisfaction with saline ultrasound versus office hysteroscopy for uterine cavity evaluation prior to in vitro fertilization: a randomized controlled trial

PURPOSE

To compare patient and provider satisfaction with saline ultrasound (SIS) versus office hysteroscopy for cavity evaluation prior to in vitro fertilization (IVF) and to assess the capability of hysteroscopy to manage pathology at time of diagnosis to reduce delays and supernumerary procedures.

METHODS

This was a randomized, controlled trial in a university fertility clinic. One hundred enrolled subjects undergoing routine uterine cavity evaluation prior to planned embryo transfer were randomized to SIS or office hysteroscopy without anesthesia. Subjects and providers completed surveys about their experience. Subjects with findings on SIS had a hysteroscopy performed or scheduled for further evaluation. Those with hysteroscopy findings had management attempted within the same procedure.

RESULTS

Overall patient satisfaction was high and did not differ between groups, while providers indicated that hysteroscopy provided a better cavity evaluation. There was no difference in time to complete procedures between groups. Pain score on a ten-scale was slightly higher in the hysteroscopy group compared to the SIS group (3.38 ± 1.85 vs. 2.44 ± 1.64, p < 0.01), but this did not impact satisfaction scores. Although pathology was found in a similar rate (22% vs. 36% for SIS and HSC groups, respectively), those in the SIS group all required secondary procedures, while only 1/17 did in the HSC group (p < 0.01).

CONCLUSION

Although the hysteroscopy group exhibited slightly higher pain scores, overall patient and provider satisfaction was high and similar between groups. There were significantly fewer secondary procedures and delays in the hysteroscopy group. Hysteroscopy is a reasonable first line screening tool for patients requiring cavity evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04415489.

Outpatient uterine assessment and treatment unit in patients with abnormal uterine bleeding: an economic modelling study

BACKGROUND

Most often in Canada, the evaluation and management of abnormal uterine bleeding occurs under general anesthesia in the operating room. We aimed to assess the potential cost-effectiveness of an outpatient uterine assessment and treatment unit (UATU) compared with the current standard of care when diagnosing and treating abnormal uterine bleeding in women.

METHODS

We performed a cost-effectiveness analysis and developed a probabilistic decision tree model to simulate the total costs and outcomes of women receiving outpatient UATU or usual care over a 1-year time horizon (Apr. 1, 2014, to Mar. 31, 2017) at a tertiary care hospital in Ontario, Canada. Probabilities, resource use and time to diagnosis and treatment were obtained from a retrospective chart review of 200 randomly selected women who presented with abnormal uterine bleeding. Results were expressed as overall cost and time savings per patient. Costs are reported in 2018 Canadian dollars.

RESULTS

Compared with usual care, care in the UATU was associated with a decrease in overall cost ($1332, 95% confidence interval [CI] -$1742 to -$1008) and a decrease in overall time to treatment (-75, 95% CI -89 to -63, d). The point at which the UATU would no longer be cost saving is if the additional cost to operate and maintain the UATU is greater than $1600 per patient.

INTERPRETATION

From the perspective of Canada's health care system, an outpatient UATU is more cost effective than usual care and saves time. Future studies should focus on the relative efficacy of a UATU and the total budget required to operate and maintain a UATU.

Advanced Hysteroscopic Surgery: Quality Assurance in Teaching Hospitals

Advanced hysteroscopic surgery (AHS) is a vitally important technique in the armamentarium for the management of many day-to-day clinical problems, such as menorrhagia, surgical excision of uterine myomata and septa in the management of female infertility, hysteroscopic excision of chronically retained products of conception (placenta accreta), and surgical removal of intramural ectopic pregnancy. In today's climate of accountability, it is necessary that gynecologists take a more active role in assuring the quality of their work. In this article, we discuss the quality assurance system from the point of view of the surgical audit meetings in some of the major teaching hospitals affiliated with the University of Queensland (Brisbane, Queensland, Australia).