Office Operative Hysteroscopy: An Update

No pain relief by virtual reality during hysterosalpingography (HSG): results from a randomized controlled trial

STUDY QUESTION

Is virtual reality (VR) an effective non-pharmacological tool to reduce procedural pain during hysterosalpingography (HSG)?

SUMMARY ANSWER

An HSG with VR does not reduce procedural pain scores compared to an HSG without VR.

WHAT IS KNOWN ALREADY

An HSG is often experienced as painful and uncomfortable. VR has been proven successful to reduce acute procedural pain during a variety of medical procedures and interventions.

STUDY DESIGN, SIZE, DURATION

We performed a two-centre open-label randomized controlled trial between January 2021 and October 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women scheduled for HSG as part of their infertility work-up were screened for participation. After informed consent, women were randomized between HSG with or without VR. Due to the nature of the intervention, the study was not blinded. VR was administered by a head-mounted device displaying nature movies and/or relaxation exercises. The primary endpoint was procedural pain measured using VAS (scale 0.0-10.0 cm). Procedural pain was divided into overall pain score and peak pain score during the procedure. It was measured immediately after HSG. Secondary endpoints included patient satisfaction, VR preferences, and adverse effects of VR.

MAIN RESULTS AND THE ROLE OF CHANCE

We included a total of 134 women, 69 to the intervention group (HSG with VR) and 65 to the control group (HSG without VR). The mean VAS for peak pain was 6.80 cm (SD 2.25) in the intervention group versus 6.60 cm (SD 2.40) in the control group (mean difference 0.28 (95% CI -0.57, 1.12), P = 0.52). The mean VAS for overall pain was 5.00 cm (SD 2.10) in the intervention group versus 4.90 cm (SD 2.13) in the control group (mean difference 0.06 (95% CI -0.71, 0.84), P = 0.88). The expectation that VR would be a good distraction from pain during HSG was correlated with both overall and peak pain scores. When correcting for this expectation, we found that women in the intervention group reported significantly higher scores, both in peak (adjusted MD 0.58 (95% CI -0.81, 1.97), P = 0.021) and overall (adjusted MD 0.43 (95% CI -0.84, 1.71), P = 0.013) pain, compared to the control group. There were no differences in the prevalence of symptoms that were considered as adverse effects of VR.

LIMITATIONS, REASONS FOR CAUTION

The study was not blinded. Reasons for declining participation in the study were anxiety or wanting full control during HSG, which might have created selection bias. The distraction score possibly indicates that the level of VR immersiveness was not optimal due to the lack of sound and/or the type of VR applications. Future studies should investigate whether more immersive or interactive VR applications could decrease procedural pain scores during HSG.

WIDER IMPLICATIONS OF THE FINDINGS

Since VR does not reduce procedural pain, this additional tool should not be used during HSG.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this study. KR and AvH report receiving a travel grant from Merck outside the scope of this study. BM is supported by a National Health and Medical Research Council (NHMRC) investigator grant (GNT1176437) and BM reports consultancy for Merck, Organon, and Norgine and travel and research funding from Merck. BM holds stock for ObsEva. CL reports receiving research grants from Merck, and Ferring. KD and VM report receiving travel and speaker's fees from Guerbet and research grants from Guerbet. VM also reports research grants from Merck and Ferring. The remaining authors have nothing to declare.

TRIAL REGISTRATION NUMBER

The trial is registered prospectively in the Netherlands Trial Register (trialregister.nl registration number NL9203, currently accessible on trialsearch.who.int).

TRIAL REGISTRATION DATE

16-01-2021.

DATE OF FIRST PATIENT’S ENROLMENT

The first participant was enrolled on 19 January 2021.

The use of oral nomegestrol acetate/estradiol in rapid and random start preparation of endometrium before office hysteroscopic polypectomies: A multicenter, prospective, randomized controlled trial

OBJECTIVE

To evaluate the use of oral nomegestrol acetate/estradiol in random start rapid preparation of endometrium before office hysteroscopic polypectomy.

STUDY DESIGN

Multicenter, prospective, randomized controlled trial.

SETTING

University hospitals.

PARTICIPANTS

80 adult women undergoing office hysteroscopic polypectomy between January 2023 and March 2024 were randomized to intervention (n = 40) or control (n = 40). Exclusion criteria included the presence of endouterine pathology other than endometrial polyps solely.

METHODS

Subjects in the intervention group were treated with oral nomegestrol acetate/estradiol 1.5 mg/2.5 mg/day started taking the drug from an indefinite time in the menstrual cycle (random start) for 14 days. Subjects in the control group did not receive any pharmaceutical treatment and underwent polypectomy between days 8 and 11 of the menstrual cycle.

RESULTS

On the day of the procedure, the difference in pre- and post-office hysteroscopic polypectomy endometrial ultrasound thickness was statistically significant between the two groups, with endometrial thickness in both measurements being thinner for the intervention group (p < 0.001). In the nomegestrol acetate/estradiol-treated group, compared with the control, there was also a statistically significant difference in the physician's assessment of the quality of endometrial preparation (p < 0.001), the quality of visualization of the uterine cavity (p < 0.001), and satisfaction with the performance of the procedure (p < 0.001). Finally, all surgical outcomes analyzed were better in the treatment group.

CONCLUSION

Treatment with nomegestrol acetate/estradiol could provide rapid, satisfactory and low-cost preparation of the endometrium before office polypectomy, thus improving surgical performance and woman's compliance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06316219.

Feasibility of Office-based Operative Hysteroscopy by a Tissue Removal System without Anesthesia

STUDY OBJECTIVE

To investigate the feasibility of operative hysteroscopy by a hysteroscopic tissue removal system (HTRS) without anesthesia in women with endometrial polyps (EP) or retained products of conception (RPOC).

DESIGN

Prospective observational cohort study.

SETTING

University-affiliated Department of Obstetrics and Gynecology.

PATIENTS

Consenting women aged >18 years diagnosed with EP or RPOC from 9/2022 to 8/2023 confirmed by a prior office hysteroscopy.

INTERVENTIONS

Office-based vaginoscopic operative hysteroscopy without anesthesia using the Mini-Elite Truclear HTRS. Oral misoprostol was prescribed for cervical ripening. The patients rated intraoperative and 5-minute postoperative pain levels on a visual analog scale, with mild pain defined as a score of 0 to 4, moderate as 5 to 7, and severe as 8 to 10. A successful procedure was defined as complete removal of the pathology.

MEASUREMENTS AND MAIN RESULTS

Fifty patients were included in this pilot study, and 47 (94.0%) procedures were completed successfully, including 21/24 (87.5%) cases of EP and all cases of RPOC (26/26, p = .06). No intra- or postoperative complications occurred. The intraoperative pain levels were rated as mild, moderate, and severe by 26 (52.0%), 16 (32.0%) and 8 (16.0%) patients, respectively. Severe intraoperative pain was more common in nulliparous women and those >10 years from their last vaginal delivery and was not associated with patient age, menopausal status, presence of abnormal uterine bleeding, or pathology size. Severe postoperative pain, reported by 5 (10.0%) patients, was significantly associated with removal of EP compared with RPOC, longer operative time, and nulliparity or >10 years from the last vaginal delivery. The procedure was considered acceptable by 46 (92.0%) patients, and 45 (90.0%) would recommend it to a friend/relative.

CONCLUSIONS

Office-based operative hysteroscopy by the HTRS is successful and well tolerated by most women, especially for RPOC removal.

Barriers to Office Hysteroscopy in Fellowship Education and Practice

STUDY OBJECTIVE

To identify the top 3 perceived barriers to performing office hysteroscopy (OH) by minimally invasive gynecologic surgery (MIGS) faculty and fellows and identify opportunities for education on this key topic that will be most effective in fellowship training and MIGS practice.

DESIGN

Cross-sectional survey study targeted at all American Association of Gynecologic Laparoscopists-accredited Fellowship in Minimally Invasive Gynecologic Surgery fellows, program directors, and associate program directors in February to April 2022. The survey was designed by faculty who have extensive experience in OH procedures. In addition, a literature search was performed to aid with question design.

SETTING, PATIENTS, AND INTERVENTIONS

This was a REDCap electronic survey administered through the Fellowship in Minimally Invasive Gynecologic Surgery listserv. No additional follow-up was performed after survey completion. The 15-minute survey was sent to 60 program directors, 92 assistant program directors, and 158 fellows, including the incoming class of 2024 and the 2022 fellowship graduates.

MEASUREMENTS AND MAIN RESULTS

A total of 93 responses were received; 67% of respondents performed OH but 73% of those performed 5 procedures or less per month. Most participants controlled pain with nonsteroidal anti-inflammatory drugs +/- paracervical block. The most common perceived barrier to performing OH was concern over pain management. Other commonly cited concerns were equipment costs, sterilization costs, and office staff training; 37% to 44% of respondents also cited lack of departmental support and insufficient clinic time, respectively, as barriers, and 56% indicated they are interested in educational materials on OH.

CONCLUSION

Our study suggests general interest in, but a low volume of, OH among MIGS fellows and faculty. The most common perceived barrier was concern regarding pain management. This has been well studied in the literature and likely presents an area for greater education to improve OH utilization. We also uncovered concerns regarding systemic barriers, such as equipment costs, departmental support, and clinic structure. This is an area for further research and advocacy efforts to address barriers to OH on a system level.

Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity

BACKGROUND

To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal.

PURPOSE

In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition.

METHODS

The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included.

RESULTS

Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments.

CONCLUSIONS

Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists.

Developing a Nomogram for Prioritizing Hysteroscopy in Endometrial Cancer Diagnosis: A Case-Control Study

(1) Background: The pandemic led to significant healthcare disruptions, resulting in postponed surgeries and extended waiting times for non-urgent treatments, including hysteroscopies essential for diagnosing endometrial cancer. This study aims to formulate a risk stratification model to enhance the prioritization of hysteroscopy procedures in Brazil; (2) Methods: A case-control study was conducted at Vila Santa Catarina Hospital in São Paulo, analyzing the medical records of 2103 women who underwent hysteroscopy between March 2019 and March 2022. We used bivariate analysis and multivariate linear regression to identify risk factors associated with endometrial cancer and formulate a nomogram; (3) Results: The findings revealed a 5.5% incidence of pre-invasive and invasive endometrial disease in the study population, with an average waiting time of 120 days for hysteroscopy procedures. The main risk factors identified were hypertension, diabetes, postmenopausal bleeding, and obesity; (4) Conclusions: This research highlights the urgent need for efficient prioritization of hysteroscopy procedures in the wake of the pandemic. The developed nomogram is an innovative tool for identifying patients at higher risk of endometrial cancer, thus facilitating timely diagnosis and treatment and improving overall patient outcomes in a strained healthcare system.

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.

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.

Diode laser use in hysteroscopic surgery: current status and future perspectives

Recent advances in surgical technology and innovative techniques have revolutionized surgical gynecology, including transcervical hysteroscopic procedures. Surgical lasers (Nd-Yag, Argon, diode, and CO2 lasers) have been promoted to remove a variety of gynecological pathologies. For hysteroscopic surgery, the diode laser represents the most versatile and feasible innovation, with simultaneous cut and coagulate action, providing improved hemostasis compared with CO2 laser. The newest diode laser devices exhibit increased power and a dual wavelength, to work precisely with reduced thermal dispersion and minimal damage to surrounding tissues. Their efficacy and safety have been validated both in the hospitals as well as in the office setting. Updated evidence reports that several hysteroscopic procedures, including endometrial polypectomies, myomectomies and metroplasties can be successfully performed with a diode laser. Therefore, this review aimed to give a deeper understanding of the role of laser energy in gynecology and subsequently in hysteroscopy in order to safely incorporate this technology into clinical practice.

Comparing endometrial biopsy results with hysteroscopic pathology in women presenting with abnormal and postmenopausal uterine bleeding

OBJECTIVE

To compare pathology results after office-based blind endometrial biopsy and pathology results from hysteroscopy in women presenting with abnormal uterine bleeding (AUB).

METHODS

A retrospective cohort study of biologic women presenting with AUB at a tertiary care referral care center. Patients were included if they underwent evaluation with blind endometrial biopsy performed in the office followed by hysteroscopy within one year. Hysteroscopic findings and pathology were correlated with index endometrial biopsy findings.

RESULTS

689 patients met inclusion criteria. The mean age and BMI were 49 (±10) years and 31 (±8) kg/m2. The median duration of bleeding leading up to presentation was of 3.5 (1.5-9) months. Of the patients who had operative hysteroscopic pathology demonstrating endometrial polyp, 30.6 % (81) had a polyp detected on office endometrial biopsy. Of the patients who had hysteroscopic pathology demonstrating intracavitary fibroids, 0 % (0) were detected on endometrial biopsy. Of the patients who had hyperplasia without atypia on hysteroscopy, 28.6 % (4) were detected or suspected on endometrial biopsy. Of the patients who had hyperplasia with atypia on hysteroscopy, 5.9 % (1) were detected or suspected on endometrial biopsy. There were 12 cases of confirmed or suspected malignancy on hysteroscopy, of which 8.3 % (1) were detected on endometrial biopsy.

CONCLUSION

Concordance between focal findings on office hysteroscopy and endometrial biopsy is low. Endometrial biopsy when malignancy is suspected has been shown to be of benefit, but in the setting of suspected benign focal pathology, blind assessment of the endometrial cavity for definitive diagnosis should be abandoned. In women with symptomatic uterine bleeding, hysteroscopic visualization is associated with increased sensitivity in identifying intrauterine pathology.

FIGO best practice guidance in surgical consent

Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure-specific checklists for the most common obstetric and gynecological procedures.

Does virtual reality technology reduce pain and anxiety during outpatient hysteroscopy? A randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of virtual reality technology in reducing pain and anxiety during outpatient hysteroscopy.

DESIGN

A prospective randomised controlled trial.

SETTING

A London University Teaching Hospital.

POPULATION

Women aged 18-70 years undergoing outpatient hysteroscopy procedures.

METHODS

An unblinded randomised controlled trial was performed between March and October 2022 comparing standard outpatient hysteroscopy care with standard care with the addition of a virtual reality headset playing a virtual reality immersive scenario as a distraction technique.

MAIN OUTCOME MEASURES

Pain and anxiety numeric rating scores (NRS) from 0 to 11.

RESULTS

Eighty-three participants were randomly allocated to the control (n = 42) and virtual reality groups (n = 41). The virtual reality group experienced significantly less anxiety during the procedure than the control group (mean NRS 3.29 versus 4.73, mean difference 1.50; 95% confidence interval [CI] 0.12-2.88; P = 0.03). There was no difference in reported average pain (mean NRS 3.73. versus 4.24, mean difference 0.51; 95% CI -1.76 to 0.64; p = 0.41) or maximum pain scores (mean NRS 5.32 versus 5.07, mean difference 0.25; 95% CI -1.05 to 1.55; P = 0.71).

CONCLUSIONS

The use of virtual reality technology as an adjunct to standard care can reduce patient-reported anxiety but not pain during outpatient hysteroscopy procedures. Continued improvements in the technology and the development of increasingly immersive environments may continue to increase the potential to improve the patient experience in this setting.

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.

Nonsteroidal anti-inflammatory drug with a local anesthetic compared to nonsteroidal anti-inflammatory drug alone significantly reduce the pain associated with vaginoscopic office hysteroscopy

INTRODUCTION AND OBJECTIVES

Pain is the most common cause of office hysteroscopy (OH) failure. There is no consensus on alleviation of pain during OH. The aim was to compare the effectiveness of pain-relieving methods during OH.

STUDY DESIGN

A prospective randomized open-label trial included women subjected to OH. All women received 100 mg of ketoprofen intravenously pre-procedure. Women were randomly assigned to 3 arms: A) no local anesthesia, B) infiltration anesthesia with 20 ml of 1% lidocaine solution, C) paracervical block with 20 ml of 1% lidocaine solution. Karl Storz Bettocchi® rigid hysteroscope with a 5 mm operative sheath was used. Intensity of pain in numeric rating scale (NRS), intensity of cervical bleeding, frequency of vasovagal episodes, and failure rate were compared.

RESULTS

The study involved 201 women, 67 in each arm. NRS value during OH was higher in arm A than in B and C (6.3 vs. 5.1 vs. 5.0; p = 0.01). NRS value after OH did not differ and in all arms pain was imperceptible (p = 0.007). Cervical bleeding was more frequent in arm B than in A and C (76.1% vs. 33.4% vs. 35.9%; p < 0.0001), but its intensity did not differ from the other arms (p = 0.3). Vasovagal episode was most common in arm B (p = 0.048). There was no difference in the failure rate between the arms (p = 0.08).

CONCLUSIONS

The paracervical block, albeit technically the most laborious, has proven to be the most beneficial for the patient in terms of overall comfort and for the surgeon regarding feasibility.

The effect of music intervention in decreasing pain and anxiety during outpatient hysteroscopy procedure: a systematic review and meta-analysis of randomized control trials

BACKGROUND

Hysteroscopy is a common outpatient procedure but procedural pain limits its use. Music could be used as a pain-relieving intervention. We performed a systematic review and meta-analysis to investigate the effect of music on pain and anxiety during outpatient hysteroscopy.

METHODS

Four electronic databases were searched: PubMed, Scopus, Web of Science, and Cochrane Library, from inception to September 2022. We included only the Randomized Controlled Trials (RCTs) that investigated the effect of music on women who underwent outpatient hysteroscopy in reducing pain and anxiety levels compared to no music. We assessed the quality of included RCTs using the risk of bias tool 1 reported in the Cochrane Handbook of Systematic Reviews of Interventions. Data were pooled as the Mean Differences (MDs) with a 95% Confidence Interval (CI) in a random-effects model, using Review Manager 5.3 software. Also, we assessed the evidence of the results using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Three RCTs (540 women) were included. Music significantly reduced visual analogue scale (VAS) pain scores as well as State-Trait Anxiety Inventory (STAI) scores compared to controls (MD = -1.28; 95% CI [-2.19, -0.36]; P = 0.007) and (MD = -3.91; 95% CI [-6.98, -0.85]; P = 0.01) respectively. Also, the decrease in VAS score for pain was significantly greater in the music group (MD = 1.44; 95% CI [0.44, 2.45]; P = 0.005). However, the change in STAI showed no significant difference between the two groups. The GRADE ratings for all outcomes were very low.

CONCLUSION

Music is a potentially promising method for controlling pain for patients undergoing outpatient hysteroscopy; however, its effect in controlling anxiety is controversial.

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.

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.

Minimally invasive approaches for the early detection of endometrial cancer

Endometrial cancer (EC) is one of the most common gynecologic cancers and its incidence is rising globally. Although advanced EC has a poor prognosis; diagnosing EC at an earlier stage could improve long-term patient outcomes. However, there is no consensus on the early detection strategies for EC and the current diagnostic practices such as transvaginal ultrasound, hysteroscopy and endometrial biopsy are invasive, costly and low in specificity. Thus, accurate and less invasive screening tests that detect EC in women with early stages of the disease are needed. Current research has revolutionized novel EC early detection methodologies in many aspects. This review aims to comprehensively characterizes minimally invasive screening techniques that can be applied to EC in the future, and fully demonstrate their potential in the early detection of EC.

Outpatient Hysteroscopic Polypectomy-A Retrospective Study Comparing Rigid and Semirigid Office Hysteroscopes

Endometrial polyps are one of the most common pathological conditions in gynecology. Hysteroscopy is the gold standard for the diagnosis and treatment of endometrial polyps. The purpose of this multicenter, retrospective study was to compare patients' pain perception during an operative hysteroscopic endometrial polypectomy in an outpatient setting with two different hysteroscopes (rigid and semirigid) and to identify some clinical and intraoperative characteristics that are related to worsening pain during the procedure. We included women that underwent, at the same time as an diagnostic hysteroscopy, the complete removal of an endometrial polyp (using the see-and-treat strategy) without any kind of analgesia. A total of 166 patients were enrolled, of which 102 patients underwent a polypectomy with a semirigid hysteroscope and 64 patients underwent the procedure with a rigid hysteroscope. No differences were found during the diagnostic step; on the contrary, after the operative procedure, a statistically significant greater degree of pain was reported when the semirigid hysteroscope was used. Cervical stenosis and menopausal status were risk factors for pain both in the diagnostic step and in the operative one. Our results confirm that operative hysteroscopic endometrial polypectomy in an outpatient setting is an effective, safe, and well-tolerated procedure and indicate that it might be better tolerated if a rigid rather than semirigid instrument is used.

Pharmacologic Interventions to Minimize Fluid Absorption at the Time of Hysteroscopy: A Systematic Review and Meta-analysis

OBJECTIVE

To assess which interventions are effective in reducing fluid absorption at the time of hysteroscopy.

DATA SOURCE

Ovid MEDLINE, Ovid EMBASE, PubMed (non-MEDLINE records only), EBM Reviews-Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov , and Web of Science were searched from inception to February 2022 without restriction on language or geographic origin.

METHODS OF STUDY SELECTION

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, all English-language, full-text articles reporting fluid balance, with an intervention and comparator arm, were included. Title and abstract screening and full-text review were completed independently by two authors. Conflicts were resolved through discussion and consensus. Studies' risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale for observational studies.

TABULATION, INTEGRATION, AND RESULTS

The search identified 906 studies, 28 of which were eligible for inclusion, examining the following interventions: gonadotropin-releasing hormone (GnRH) agonist; ulipristal acetate; vasopressin; danazol; oxytocin; and local, general, and regional anesthesia. A significant reduction in mean fluid absorption was seen in patients preoperatively treated with danazol (-175.7 mL, 95% CI -325.4 to -26.0) and a GnRH agonist (-139.68 mL, 95% CI -203.2, -76.2) compared with patients in a control group. Ulipristal acetate and type of anesthesia showed no difference. Data on type of anesthesia and vasopressin use were not amenable to meta-analysis; however, four studies favored vasopressin over control regarding fluid absorption. Mean operative time was reduced after preoperative treatment with ulipristal acetate (-7.1 min, 95% CI -11.31 to -2.9), danazol (-7.5 min, 95% CI -8.7 to -6.3), and a GnRH agonist (-3.3 min, 95% CI -5.6 to -0.98).

CONCLUSION

Preoperative treatment with a GnRH agonist and danazol were both found to be effective in reducing fluid absorption and operative time across a range of hysteroscopic procedures. High-quality research aimed at evaluating other interventions, such as combined hormonal contraception, progestin therapy, and vasopressin, are still lacking in the literature.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021233804.

Evaluation of the timing and safety of hysteroscopic myomectomy of large submucosal fibroids pretreated by high intensity focused ultrasound

OBJECTIVES

To evaluate the timing and safety of hysteroscopic myomectomy for large submucosal fibroids pretreated with high intensity focused ultrasound (HIFU).

MATERIALS AND METHODS

From June 2011 to December 2020, 74 patients with solitary submucousal fibroid with size larger than 4 cm who received HIFU treatment followed by hysteroscopic myomectomy were enrolled.

RESULTS

The average age of patients was 40.2 ± 6.7 years. Among them, 1 had type 0, 18 had type I and 55 patients had type II submucosal fibroids. The mean diameter of fibroids was 5.7 ± 1.2 cm. All patients completed HIFU in one session, and the median non-perfused volume (NPV) ratio achieved in fibroids was 90.5%. Hysteroscopic myomectomy was performed in 0-1, 1-3, 3-6, and 6-12 months after HIFU. The mean shrinkage rate of fibroids post-HIFU was 68.19 ± 19.86%, 61.10 ± 16.89%, and 63.76 ± 26.68% in 1-3 months, 3-6 months and 6-12 months, respectively. All patients completed hysteroscopic myomectomy successfully, and no intrauterine adhesion after HIFU was observed. The complete resection of fibroids achieved in 69 patients in one session of the procedure. The mean operation time was 66.66 ± 31.61 min, the median blood loss was 20 ml, and the median distention medium deficit was 275 ml. No significant difference was observed in the operation time, blood loss and distention medium deficit among patients who received hysteroscopic myomectomy at different time points (p > 0.05).

CONCLUSIONS

HIFU can be used as a pretreatment for large submucosal fibroids before hysteroscopic myomectomy. Based on our results, hysteroscopic myomectomy could be performed at any time point, even within 1 month after HIFU.

Predictive Factors of Tolerance in Office Hysteroscopy - a 3-Year Analysis from a Tertiary Center

OBJECTIVE

 Pain is the primary limitation to performing hysteroscopy. We aimed to evaluate the predictive factors of low tolerance to office hysteroscopic procedures.

METHODS

 Retrospective cohort study of the patients who underwent office hysteroscopy from January 2018 to December 2020 at a tertiary care center. Pain tolerance to office-based hysteroscopy was subjectively assessed by the operator as terrible, poor, moderate, good, or excellent. Categorical variables were compared with the use of the Chi-squared test; an independent-samples t-test was conducted to compare continuous variables. Logistic regression was performed to determine the main factors associated with low procedure tolerance.

RESULTS

 A total of 1,418 office hysteroscopies were performed. The mean age of the patients was 53 ± 13.8 years; 50.8% of women were menopausal, 17.8% were nulliparous, and 68.7% had a previous vaginal delivery. A total of 42.6% of women were submitted to an operative hysteroscopy. Tolerance was categorized as terrible or poor in 14.9% of hysteroscopies and moderate, good, or excellent in 85.1%. A terrible or poor tolerance was more frequently reported in menopausal women (18.1% vs. 11.7% in premenopausal women, p = 0.001) and women with no previous vaginal delivery (18.8% vs. 12.9% in women with at least one vaginal birth, p = 0.007). Low tolerance led more often to scheduling a second hysteroscopic procedure under anesthesia (56.4% vs. 17.5% in reasonable-to-excellent tolerance, p < 0.0005).

CONCLUSION

 Office hysteroscopy was a well-tolerated procedure in our experience, but menopause and lack of previous vaginal delivery were associated with low tolerance. These patients are more likely to benefit from pain relief measures during office hysteroscopy.

Massively parallel sequencing of endometrial lavage specimens for the detection of cancer-associated mutations in atypical and non-atypical endometrial hyperplasia

Background

Endometrial hyperplasia (EH), particularly with atypia, is considered an antecedent of endometrial adenocarcinoma. In this study, we aimed to apply massively parallel sequencing of endometrial lavage specimens for the detection of cancer-associated mutations in atypical (AEH) and non-atypical endometrial hyperplasia (NEH). The identified alterations were compared with those detected in tissue samples.

Materials and methods

Endometrial lavage specimens and parallel biopsy samples (n = 11 for AEH and n = 9 for NEH) were obtained from 18 women (9 with AEH and 9 with NEH) who received an office hysteroscopy for suspected endometrial lesions. All samples were tested for somatic mutations in hotspot regions of 72 cancer-associated genes by massively parallel sequencing.

Results

On analyzing sequencing data, the presence of at least one cancer-associated gene mutation was identified in 72.7 and 44.4% of endometrial lavage specimens obtained from women with AEH and NEH, respectively (p = 0.362, 95% confidence interval = 0.72-3.70). The concordance rates between mutations identified in endometrial lavage specimens and endometrial biopsies were 54.5 and 0% from women with AEH and NEH, respectively (p = 0.014). A patient with NEH harbored mutations in endometrial lavage with the same mutations found in the tissue specimen at low allele frequency below detection cutoff, raising the suspicion of missed focal atypia.

Conclusion

Endometrial hyperplasia is characterized by a high burden of cancer-associated mutations, particularly in the presence of atypia. Our study, albeit performed with a relatively small number of samples, indicates that their detection by massively parallel sequencing of endometrial lavage is feasible. Our findings may allow tailoring of endometrial biopsies to the individual risk of AEH; additionally, they can pave the way toward less invasive surveillance protocols in patients with known EH.

Vasovagal Syncope during Office Hysteroscopy—A Frequently Overlooked Unpleasant Complication

Due to technological advancements in miniaturization of instruments and improved optics, the number of office hysteroscopic procedures has increased over time. Office hysteroscopy is preferred due to avoidance of general anesthesia and decreased overall cost. Vasovagal syncope has been implied as the most common complication. Vasovagal syncope is associated with inappropriate reflex vasodilation and bradycardia in the setting of an acute malfunction between the autonomic nervous system and the cardiovascular system; however, there is no mortality associated with vasovagal syncope. A management strategy for acute vasovagal reflex during office hysteroscopy is proposed in order to manage this common complication.

Analysis of endometrial lavage microbiota reveals an increased relative abundance of the plastic-degrading bacteria Bacillus pseudofirmus and Stenotrophomonas rhizophila in women with endometrial cancer/endometrial hyperplasia

The pathogenic influences of uterine bacteria on endometrial carcinogenesis remain unclear. The aim of this pilot study was to compare the microbiota composition of endometrial lavage samples obtained from women with either endometrial hyperplasia (EH) or endometrial cancer (EC) versus those with benign uterine conditions. We hypothesized that specific microbiota signatures would distinguish between the two groups, possibly leading to the identification of bacterial species associated with endometrial tumorigenesis. A total of 35 endometrial lavage specimens (EH, n = 18; EC, n = 7; metastatic EC, n = 2; benign endometrial lesions, n = 8) were collected from 32 women who had undergone office hysteroscopy. Microbiota composition was determined by sequencing the V3−V4 region of 16S rRNA genes and results were validated by real-time qPCR in 46 patients with EC/EH and 13 control women. Surprisingly, we found that Bacillus pseudofirmus and Stenotrophomonas rhizophila – two plastic-degrading bacterial species – were over-represented in endometrial lavage specimens collected from patients with EC/EH. Using computational analysis, we found that the functional profile of endometrial microbiota in EC/EH was associated with fatty acid and amino acid metabolism. In summary, our hypothesis-generating data indicate that the plastic-degrading bacteria Bacillus pseudofirmus and Stenotrophomonas rhizophila are over-represented within the endometrial lavage microbiota of women with EC/EH living in Taiwan. Whether this may be related to plastic pollution deserves further investigation.

The Choice of Anesthetic Drugs in Outpatient Hysteroscopic Surgery: A Systematic Review and Network Meta-Analysis

Objective

Hysteroscopy is a minimally invasive gynecologic technique that is widely practiced in outpatient procedures. The choice of anesthesia is a key factor for the surgical outcome and postoperative recovery. This study was conducted to assess the effects of different anesthetic modalities based on dexmedetomidine in outpatient hysteroscopic surgery anesthesia.

Methods

We did a systematic review and network meta-analysis of outpatient hysteroscopic surgery anesthesia. We searched Pubmed, Embase, and Cochrane-Library from database inception to December 31, 2021. Duplicate literature was excluded and screened separately for initial screening at three tiers: article title, abstract, and full text before deciding whether to include in this study against the above criteria. Results after analysis of categorical variables were expressed as ORR Ratio (95% CI) and continuous variables were expressed as Mean Difference (95% CI). Data collation and analyses were performed using the gemtc package in the R language.

Results

Four trials were finally included with data for 301 participants, three anesthetic drugs, and five anesthetic modalities. A fixed-effects model was used for the different anesthesia modalities without significant heterogeneity (all I2<20%) in the analysis of adverse events (AEs), the incidence of respiratory depression, operative time, and time in the post-anesthesia care unit (PACU). Remimazolam tosylate was associated with a lower incidence of AEs versus dexmedetomidine, and significant differences between dexmedetomidine and propofol were absent. Propofol and various doses of remimazolam tosylate resulted in a lower incidence of respiratory depression versus dexmedetomidine, with an absence of differences between propofol and dexmedetomidine. The operative time for different anesthetic modalities was, in descending order, dexmedetomidine < remimazolam tosylate (0.60 mg/kg/h <0.48 mg/kg/h) < propofol < remimazolam tosylate (1.00 mg/kg/h), despite the absence of intergroup differences. Propofol was associated with a longer time in PACU versus dexmedetomidine and remimazolam tosylate (1.00 mg/kg/h); those of dexmedetomidine and remimazolam tosylate (1.00 mg/kg/h) were similar. The time in PACU for different anesthetic modalities, in descending order, was dexmedetomidine < remimazolam tosylate (1.00 mg/kg/h) < propofol. Propofol was associated with a longer time in PACU versus dexmedetomidine and remimazolam tosylate.

Conclusion

In outpatient hysteroscopic surgery anesthesia, dexmedetomidine was associated with a higher incidence of AEs and respiratory depression and a shorter operative time and time in PACU versus remimazolam tosylate and propofol. Remimazolam tosylate showed safety benefits with a similar duration of PACU stay versus dexmedetomidine. Therefore, the choice of anesthetic drugs in outpatient surgery requires consideration of the patient's conditions and preferences.

Effect of misoprostol on cervical transition pain in office hysteroscopy: Results of a tertiary center

Objective: Office hysteroscopy is a method that has become increasingly popular because of its low complication rate, rapid recovery, and cost-effectiveness. Pain is the biggest obstacle to the successful completion of office hysteroscopy procedures. Thus, the present study aimed to investigate the efficacy of misoprostol in providing cervical ripening, and thus reducing pain during the cervical transition of hysteroscopy. Methods: This research was conducted as an observational case-control study. Seventy-nine patients who underwent office hysteroscopy were included. Twenty-nine patients were administered 200 μg of vaginal misoprostol 4 h before office hysteroscopy, whereas the control group consisting of 50 patients was not provided with premedication for cervical dilatation. Patients were asked to rate their pain between 0 and 10 using the visual analog scale (VAS) 30 min after the procedure. Results: VAS pain scores after diagnostic office hysteroscopy (3.61 ± 0.61) and operative office hysteroscopy (4.45 ± 0.82) were significantly lower in the misoprostol group than in the control group patients. None of the patients experienced serious side effects caused by misoprostol and requested to end the procedure. Conclusion: A significant reduction in the VAS pain score was detected in patients who were administered 200 μg of vaginal misoprostol 4 h before office hysteroscopy. Misoprostol facilitated transition by providing cervical maturation and reduced the risk of pain-related unsuccessful hysteroscopy.

Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology

Hysteroscopy provides a minimally invasive strategy to evaluate intrauterine pathology and manage conditions such as abnormal uterine bleeding, infertility, intrauterine adhesions, müllerian anomalies, and intrauterine foreign bodies. Increasing access to hysteroscopy procedures in the office has the potential to improve patient care by minimizing financial and logistical barriers, aiding in streamlined diagnosis and treatment planning, and potentially averting unnecessary operative procedures and anesthesia. Office hysteroscopy refers to procedures performed in outpatient settings where pain management involves no medications, oral nonsedating medications, local anesthetic agents, or oral or inhaled conscious sedation. We present best practices for the implementation of hysteroscopy in an office setting. These include appropriate patient selection, optimal procedural timing, cervical preparation for patients at highest risk of cervical stenosis or pain with dilation, individualized pain-management strategies, use of distension media, and video monitoring to engage patients in the procedure. We describe miniaturized equipment for use in the office setting and "no-touch" vaginoscopic approaches to limit patient discomfort. With appropriate training and experience, office hysteroscopy presents a simple and cost-effective modality for optimizing gynecologic care for our patients.

Pain Management during Office Hysteroscopy: An Evidence-Based Approach

Background and Objectives: Hysteroscopy is a reliable technique which is highly useful for the evaluation and management of intrauterine pathology. Recently, the widespread nature of in-office procedures without the need for anesthesia has been requesting validation of practical approach in order to reduce procedure-related pain. In this regard, we performed a comprehensive review of literature regarding pain management in office hysteroscopic procedures. Materials and Methods: MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Global Health, Health Technology Assessment Database and Web of Science, other research registers (for example Clinical Trials database) were searched. We searched for all original articles regarding pain relief strategy during office hysteroscopy, without date restriction. Results have been collected and recommendations have been summarized according to the Appraisal of Guidelines for Research and Evaluation (AGREE) tool. Moreover, the strength of each recommendation was scored following the Grading of Recommendations Assessment (GRADE) system, in order to present the best available evidence. Results: Both pharmacological and non-pharmacological strategies for pain management are feasible and can be applied in office setting for hysteroscopic procedures. The selection of strategy should be modulated according to the characteristics of the patient and difficulty of the procedure. Conclusions: Accumulating evidence support the use of pharmacological and other pharmacological-free strategies for reducing pain during office hysteroscopy. Nevertheless, future research priorities should aim to identify the recommended approach (or combined approaches) according to the characteristics of the patient and difficulty of the procedure.

Towards less invasive molecular diagnostics for endometrial cancer: massively parallel sequencing of endometrial lavage specimens in women attending for an office hysteroscopy

We aimed to detect endometrial cancer (EC)-associated mutations in endometrial lavage specimens collected in an office setting and to compare the detected mutations with those identified in tissue samples. Participants included 16 women attending for an office hysteroscopy because of suspected EC between July 2020 and October 2021. Massively parallel sequencing was conducted using the targeted 72 cancer-associated genes. Endometrial lavage specimens, endometrial tissue samples, and blood samples were simultaneously sequenced to establish the concordance of genetic alterations. In this study, the vast majority of EC-associated mutations identified in lavage samples (R² = 0.948) were identical to those detected in endometrial tissues. Of the 13 patients with EC, 12 (92.3%) had at least one mutation identified in endometrial lavage samples. Notably, no mutations in lavage samples were identified in the two patients with a previous history of EC but no actual endometrial lesions, supporting a high negative predictive value of the test. A patient previously diagnosed with EC and with current evidence of atypical hyperplasia showed persisting PTEN, PIK3R1, and KRAS mutations in her endometrial lavage specimen. PTEN was the most commonly mutated gene, followed by PIK3R1, ARID1A, PIK3CA, CTNNB1, and KRAS. In conclusions, our study provides pilot evidence on the actionability of uterine lavage samples sequencing to detect EC-associated mutations in women with suspected endometrial lesions. In a precision medicine framework, the high mutational concordance between uterine lavage samples and tissue specimens may help inform less invasive diagnostic protocols and the need for ongoing surveillance in patients with EC who wished for fertility-preserving treatment. KEY MESSAGES: • Sequencing of uterine lavage samples collected by office hysteroscopy is feasible. • Most EC mutations identified in lavage were identical to endometrial tissues. • Sequencing of uterine lavage samples may help inform diagnostic protocols for EC. • This approach can be used for recurrence surveillance in patients with EC.

Direct hysteroscopic endometrial sampling and pipelle sampling in perimenopausal women

BACKGROUND

Abnormal uterine bleeding is a common cause of hospital admission in perimenopausal women. It can be the first sign of many diseases such as endometrial cancer and endometrial hyperplasia. Endometrial sampling is valuable in early diagnosis and treatment. Although hysterectomy is the gold standard in the diagnosis of endometrial pathology, it is not considered an acceptable method for diagnosis. With the principle of "see and treat, hysteroscopy seems to be the most successful method.

METHODS

After obtaining the necessary ethics committee approval, we obtained liquid-based cytology samples of our perimenopausal patients who frequently applied to our outpatient clinic with abnormal uterine bleeding. To conduct endometrial sampling of our patients, we used pipelle aspiration method in our 75-disease group and direct hysteroscopic sampling method in our other 75 disease group. We then compared the pre- and postoperative pathology results.

RESULTS

There was no statistically significant difference between preoperative and postoperative pathological results in both pipelle and hysteroscopic sampling groups.

CONCLUSIONS

Evaluation of endometrial pathologies by hysteroscopic method and pipelle method has high sensitivity and specificity. Gynecologists may determine the method preference according to the status of the health system together with their patients.

See-and-treat in-office hysteroscopy versus operative hysteroscopy for the treatment of retained products of conception: A retrospective study

AIM

To compare the efficacy and safety of in-office hysteroscopy with a see-and-treat approach with that of operative hysteroscopy for the treatment of retained products of conception (RPOC).

METHODS

We retrospectively identified all consecutive patients who underwent hysteroscopic treatment of RPOC between 2015 and 2019. We excluded patients with RPOC larger than 2 cm at preoperative transvaginal ultrasounds. Between 2015 and 2017, all hysteroscopic removals of RPOC were performed by operative hysteroscopy. Between 2018 and 2019, all cases of RPOC less than 2 cm in size were hysteroscopically removed by the see-and-treat approach in the office setting. Sociodemographic, clinical, and procedure characteristics along with complications were retrieved from medical records.

RESULTS

Between 2015 and 2019, 119 women underwent hysteroscopic removal of RPOC equal to or smaller than 2 cm: 53 patients by in-office hysteroscopy, and 66 by operative hysteroscopy. The two groups were similar in preoperative characteristics. Although the time required to complete the RPOC removal was similar, the total procedure and assistant time were significantly higher in the operative hysteroscopy group (p < 0.001). Moreover, operative hysteroscopy was associated with a higher proportion of cases complicated by excessive bleeding, cervical tear, or uterine perforation (p = 0.016). Failure to complete the procedure was similarly reported in the two groups (p = 0.58).

CONCLUSIONS

In-office hysteroscopy with the see-and-treat approach for RPOC equal to or smaller than 2 cm appears as effective as operative hysteroscopy, but safer. In-office hysteroscopy may be considered the first choice for treating RPOC equal to or smaller than 2 cm.

Uterine Septum with or without Hysteroscopic Metroplasty: Impact on Fertility and Obstetrical Outcomes-A Systematic Review and Meta-Analysis of Observational Research

Objective: we performed a systematic review/meta-analysis to evaluate the impact of septate uterus and hysteroscopic metroplasty on pregnancy rate-(PR), live birth rate-(LBR), spontaneous abortion-(SA) and preterm labor (PL) in infertile/recurrent miscarriage-(RM) patients. Data sources: a literature search of relevant papers was conducted using electronic bibliographic databases (Medline, Scopus, Embase, Science direct). Study eligibility criteria: we included in this meta-analysis all types of observational studies that evaluated the clinical impact of the uterine septum and its resection (hysteroscopic metroplasty) on reproductive and obstetrics outcomes. The population included were patients with a diagnosis of infertility or recurrent pregnancy loss. Study appraisal and synthesis methods: outcomes were evaluated according to three subgroups: (i) Women with untreated uterine septum versus women without septum (controls); (ii) Women with treated uterine septum versus women with untreated septum (controls); (iii) Women before and after septum removal. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for the outcome measures. A p-value < 0.05 was considered statistically significant. Subgroup analysis was performed according to the depth of the septum. Sources of heterogeneity were explored by meta-regression analysis according to specific features: assisted reproductive technology/spontaneous conception, study design and quality of papers included Results: data from 38 studies were extracted. (i) septum versus no septum: a lower PR and LBR were associated with septate uterus vs. controls (OR 0.45, 95% CI 0.27−0.76; p < 0.0001; and OR 0.21, 95% CI 0.12−0.39; p < 0.0001); a higher proportion of SA and PL was associated with septate uterus vs. controls (OR 4.29, 95% CI 2.90−6.36; p < 0.0001; OR 2.56, 95% CI 1.52−4.31; p = 0.0004). (ii) treated versus untreated septum: PR and PL were not different in removed vs. unremoved septum(OR 1.10, 95% CI 0.49−2.49; p = 0.82 and OR 0.81, 95% CI 0.35−1.86; p = 0.62); a lower proportion of SA was associated with removed vs. unremoved septum (OR 0.47, 95% CI 0.21−1.04; p = 0.001); (iii) before-after septum removal: the proportion of LBR was higher after the removal of septum (OR 49.58, 95% CI 29.93−82.13; p < 0.0001) and the proportion of SA and PL was lower after the removal of the septum (OR 0.02, 95% CI 0.02−0.04; p < 0.000 and OR 0.05, 95% CI 0.03−0.08; p < 0.0001) Conclusions: the results show the detrimental effect of the uterine septum on PR, LBR, SA and PL. Its treatment reduces the rate of SA.

Opinion paper: gynecological surgery in local anesthesia?

Purpuse

The paracervical block (PCB) is a local anesthesia procedure that can be used to perform gynecological surgeries without the need for further anesthesia. With the PCB, surgeries can be moved from the central operating room to outpatient operating rooms, where they can be performed without the presence of an anesthesia team.

Methods

In this paper, the indications, implementation and limitations of the procedure are discussed.

Conclusion

Especially in times of scarce staff and OR resources during the Corona pandemic, OR capacity can be expanded in this way.

[Impact of vaginal delivery history on anesthesia management of hysteroscopic surgery under intravenous general anesthesia: a cohort study of 99 patients]

OBJECTIVE

To evaluate the impact of a history of vaginal delivery on anesthesia management of patients undergoing hysteroscopic surgery under intravenous general anesthesia without tracheal intubation.

METHODS

Ninety-nine patients undergoing hysteroscopic surgery under intravenous general anesthesia were enrolled in this study, including 43 patients with (VD group) and 56 patients without a history of vaginal delivery (NVD group). For all the patients, blood pressure, heart rate (HR), blood oxygen saturation (SpO₂) and bispectral index (BIS) were recorded before anesthesia (T1), after anesthesia (T2), after cervical dilation (T3), and at 3 min after cervical dilation (T4). Propofol and etomidate doses during anesthesia induction, the total dose of propofol administered, additional intraoperative bolus dose and times of propofol, intraoperative body movement, total operation time and surgeons' satisfaction feedback scores were compared between the two groups. The postoperative awake time, recovery time, VAS score at 30 min after operation, and postoperative nausea and vomiting (PONV) were also compared.

RESULTS

There was no significant differences in SBP, DBP, HR, SpO₂, or BIS between the two groups at T1 and T2, but at T3 and T4, SBP and DBP were significantly higher in NVD group than in VD group (P < 0.01); HR was significantly higher in NVD group only at T3 (P < 0.01). The application of vasoactive drugs did not differ significantly between the two groups. The total dose of propofol, additional intraoperative dose and times of propofol were all greater in NVD group than in VD group (P < 0.01). More body movements of the patients were observed in NVD group (P < 0.01), which also had lower surgeons' satisfaction score for anesthesia (P < 0.01), higher postoperative VAS score (P < 0.05), and shorter postoperative awake time (P < 0.05) and recovery time (P < 0.01).

CONCLUSION

A history of vaginal delivery has a significant impact on anesthesia management of patients undergoing hysteroscopic surgery under intravenous general anesthesia without tracheal intubation in terms of hemodynamic changes, anesthetic medication, and postoperative recovery quality, suggesting the necessity of individualized anesthesia management for these patients.

Office Operative Hysteroscopy for the Management of Retained Products of Conception

The aim of this study was to compare office to conventional operative hysteroscopy for the treatment of retained products of conception (RPOC). This retrospective cohort study included all women who underwent hysteroscopy due to RPOC between January 2018 and December 2019, in a single tertiary medical care center. Exclusion criteria for hysteroscopy included the following: (1) proximity to delivery (up to 3 weeks); (2) hemodynamic instability; (3) active massive bleeding; and (4) genital tract infection. See-and-treat hysteroscopy (study group) outcomes were compared to operative hysteroscopy (controls). Data were collected from women's medical records. Primary outcome was defined as successful removal of all suspected RPOC with no need for additional intervention. Data are presented as median and interquartile range. During the study period, 222 women underwent hysteroscopy due to RPOC. Of them, 138 (62%) and 84 (38%) underwent see-and-treat and operative hysteroscopy, respectively. Symptomatic women were more commonly referred to operative hysteroscopy (60 (71%) vs. 54 (39%); p = 0.001). Maximal diameter of the suspected finding was smaller both by ultrasound examination (13 (10-18) vs. 18 (13-32) mm; p = 0.001) and by surgeon estimation during diagnostic hysteroscopy (12 (8-20) vs. 20 (14-30) mm; p = 0.001), in the see-and-treat compared to the operative hysteroscopy group, respectively. While comparing success rate between groups, no difference was observed. Sub-analysis by the maximal diameter of RPOC findings revealed that see-and-treat success rate is reduced as the RPOC is larger. Success rate was high and comparable to operative hysteroscopy for findings ≤ 2 cm (102/117 (87%) vs. 49/54 (91%); p = 0.79). Nevertheless, for RPOC > 2 cm, success was significantly more frequent in the operative hysteroscopy group (28/30 (93%) vs. 9/16 (57%); p = 0.002). This finding was supported by logistic regression analysis that found maximal diameter of RPOC as the only parameter associated with success rate (B = 0.96; p = 0.03). Office operative hysteroscopy is a feasible treatment option for the removal of RPOC when maximal diameter is taken under consideration due to its association to success rate.Clinical trial registration: The study protocol was approved by the "Sheba Medical Center" Review Board (ID 5200-18 SMC) on June 24, 2018.

Mini-resectoscope vs morcellator for in-office hysteroscopic myomectomy: Evaluation of results and patient satisfaction

INTRODUCTION

The development of hysteroscopic techniques has led to an advance in submucous myoma treatment, offering a safe and effective minimally invasive alternative. Our objective was to compare the results of hysteroscopic myomectomy when using whether the mini-resectoscope or the MyoSure morcellator, as well as patient satisfaction after the procedure.

MATERIAL AND METHODS

A prospective, cross-sectional, observational study including 80 patients distributed into two groups: Mini-Resectoscope group (MRG) or MyoSure group (MSG), depending on the instrument used for the in-office hysteroscopic myomectomy. Resection time, pain during entry, pain during resection, number of resections required, complete resection, and total satisfaction were recorded.

RESULTS

MSG had statistically significant shorter time of entrance. There were no other statistically significant differences between groups.

CONCLUSIONS

In-office hysteroscopic myomectomy is associated with high levels of patient satisfaction, without differences between the mini-resectoscope or the MyoSure, allowing high rates of complete resection using both instruments. Thus, it is a feasible technique which could be performed with both instruments, depending on the operator's expertise.

Mobile Hysteroscopy With the Use of a Smartphone as a Cost-Effective, Diagnostic Technique

BACKGROUND

Smartphone technology can be adapted to promote cable-free, wireless, and cost-effective diagnostic mobile office hysteroscopy.

INSTRUMENT

We developed a new cable-free setup by coupling a rigid 30°, 2-mm-diameter hysteroscope to a smartphone using a commercially available adapter and using a portable and rechargeable light-emitting diode cold light source. The new setup cost is considerably lower compared with that of a typical endoscopic tower.

EXPERIENCE

We performed both standard hysteroscopy and hysteroscopy using the new portable setup in 40 patients for a variety of benign gynecologic indications. The operating time was compared between the two methods, as was the pain perceived by the patients. Videos from the two setups were blindly reviewed and scored by experts regarding image resolution, brightness, color, and overall image quality. The new technique was acceptable for diagnosis in 97.5% of the videos.

CONCLUSION

We report a promising initial experience using a smartphone to provide a convenient, cable-free, low-cost, office hysteroscopy system.

Mechanical hysteroscopic tissue removal or hysteroscopic morcellator: understanding the past to predict the future. A narrative review

Background

In recent years, the available evidence revealed that mechanical hysteroscopic tissue removal (mHTR) systems represent a safe and effective alternative to conventional operative resectoscopic hysteroscopy to treat a diverse spectrum of intrauterine pathology including endometrial polyps, uterine myomas, removal of placental remnants and to perform targeted endometrial biopsy under direct visualisation. This innovative technology simultaneously cuts and removes the tissue, allowing one to perform the procedure in a safer, faster and more effective way compared to conventional resectoscopic surgery.

Objective

To review currently available scientific evidence concerning the use of mechanical hysteroscopic morcellators and highlight relevant aspects of the technology.

Material and Methods

A narrative review was conducted analysing the available literature regarding hysteroscopic tissue removal systems.

Main outcome measures

Characteristics of available mHTR systems, procedures they are used for, their performance including safety aspects and their comparison.

Results

A total of 7 hysteroscopic morcellators were identified. The diameter of the external sheet ranged from 5.25 to 9.0 mm, optics ranged from 0.8 to 6.3 mm with 0o angle. The cutter device diameter ranged from 2.9 to 4.5 mm most of them with rotation and reciprocation.

Conclusion

We conclude that the adoption of mHTR has shown to reduce operating time, simultaneously cutting and suctioning tissue fragments avoiding the need for multiple removal and reinsertions of the device into the uterine cavity as well as reducing the volume of distension media required to complete the procedure compared to using the hysteroscopic resectoscope.

The clinical importance of polyp size measurement through two-dimensional saline infusion sonohysterography prior to hysteroscopic resection in predicting premalignant and malignant endometrial lesions

OBJECTIVE

To evaluate the clinical importance of endometrial polyp size measured using saline infusion sonohysterography (SIS) before performing a hysteroscopic resection in predicting premalignant/malignant lesions.

METHODS

A retrospective observational study analysis was conducted of 365 patients, who underwent SIS, in a reference hospital. The longest plane of the polyp size was taken as base. Polyps were classified as benign, premalignant, or malignant.

RESULTS

The rates of premalignant and malignant lesions were 7.4% and 0.9%, respectively. The mean polyp size was 17.7 ± 0.5 mm in benign patients and 23.7 ± 1.8 mm in premalignant/malignant individuals (P < 0.001). In the group of polyps that were 0-10, 10-20, 20-30, and >30 mm, premalignancy/malignancy rates were 0.0%, 4.8%, 13.3%, and 18.8%, respectively. The cut-off value for polyp size to be able to predict lesions was calculated as 22.5 mm (sensitivity: 63%, specificity: 80%) on receiver operating characteristics curve analysis (P = 0.001, area under the curve 0.732). The power of the study was calculated as 90.86%.

CONCLUSION

During the female reproductive years, endometrial polyps smaller than 10 mm, as measured in SIS, can be followed. However, when the polyp size is 22.5 mm or more, especially in postmenopausal women, treatment should be planned.

Hysteroscopic management of intrauterine benign diseases

Hysteroscopy is the gold-standard procedure for evaluating the vagina, cervix, cervical canal and uterine cavity, with a great possibility of identifying lesions and being able to treat them at the same time in a 'See and Treat' procedure. The presence of the operative channel allows directed biopsy and excision of part of the lesions. Hysteroscopic treatment can be offered in office and hospital settings. The main difference is the use of anesthesia for hospital hysteroscopy. Office hysteroscopy has as major challenge the patient's pain threshold and the size of the lesion base. The use of the appropriate technique allows the removal of lesions even in an outpatient setting. Hospital hysteroscopy allows the use of instruments with a larger diameter and with the use of associated energy. The development of new technologies has increased the spectrum of office hysteroscopy.

Management of Cervical Ectopic Pregnancy with Small-Caliber Hysteroscopy

Background and Objectives:

Cervical ectopic pregnancy is one of the rarest forms of ectopic pregnancy. We present a single center case series of 10 cases of cervical ectopic pregnancy, where 3 patients underwent small-caliber hysteroscopy as a single treatment method.

Methods:

This was a retrospective study of women treated at our medical center with the diagnosis of cervical ectopic pregnancy from January 1, 2018 to December 31, 2020. Patient characteristics, medical history, obstetric history, diagnostic methods were collected. Small-caliber hysteroscopy treatment was performed in 3 patients and 7 patients underwent dilation and curettage (D&C).

Results:

We identified 10 patients diagnosed with cervical ectopic pregnancy who were treated at our center. Ultrasonography was used to diagnose all cervical ectopic pregnancies Three patients underwent small-caliber hysteroscopy as a single treatment option, while D&C was performed in 7 patients. Patients who underwent small-caliber hysteroscopy had a median gestational age at diagnosis of 7 weeks and initial βHCG < 10,000 mIU/mL. These patients had shorter hospital stay and a lower estimated blood loss than patients who underwent D&C.

Conclusions:

In our experience, small-caliber hysteroscopy is a safe and effective single treatment option for cervical ectopic pregnancy, but requires a skilled and experienced gynecologist.

The use of hysteroscopy in endometrial cancer: old questions and novel challenges

Endometrial cancer is the most common gynecological malignancy with a relatively good overall prognosis. It traditionally has two subtypes: type 1 (endometrioid carcinoma) and type 2 (non-endometrioid carcinoma). The prognosis is excellent for stage I endometrioid cancer, with a 5-year survival rate of 96%. However, the prognosis is much worse for women with high-risk endometrial cancer. Effective preoperative staging is important in order to tailor treatment and achieve optimal long-term survival. The majority of asymptomatic polyps detected by ultrasound are treated surgically. Conventionally, dilatation and curettage was performed to obtain a histological diagnosis, but nowadays hysteroscopy with biopsy is starting to be considered as the gold standard. Hysteroscopic resection seems to reduce the risk of underdiagnosed (atypical endometrial hyperplasia) endometrial cancer. To avoid the spread of malignant cells, hysteroscopy should be performed with concern to keep intrauterine pressure low. In comparison with cervical injection, the hysteroscopic method has a better detection rate in the para-aortic area during sentinel lymph node mapping. In the assessment of cervical involvement, the accuracy of magnetic resonance imaging is significantly higher than the accuracy of hysteroscopy. In fertility-sparing cases, hysteroscopic endometrium resection with progesterone therapy is an acceptable option.