The technique and overview of flexible hysteroscopy

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.

Abnormal uterine bleeding in a 2-month-old infant: Workup, instrumentation, and endoscopic management-A case report

A case report of a 2‐month‐old patient with severe abnormal uterine bleeding and vascular neoplastic malformation who was diagnosed and managed by endoscopic and vessel embolization therapy.

Diagnostic office hysteroscopy with the Storz TrophyScope® versus Cooper surgical Endosee®

BACKGROUND

Office hysteroscopy (OH) is becoming increasingly popular. Our objective was to determine the use patterns, reported pain scores, and success rates of OH with the 2.9 mm Storz TrophyScope^® and handheld portable Cooper surgical Endosee^® device in a clinic without previous office hysteroscopy experience.

METHODS

A prospective cohort study of a hysteroscopy quality improvement database was conducted in a tertiary care center gynecology clinic. Patients undergoing OH with either the Storz TrophyScope^® or Cooper Surgical Endosee^® device were included.

RESULTS

Of the 171 office hysteroscopies, 77 utilized the TrophyScope^®, with 8 (10%) being inadequate, while 94 utilized Endosee^®, with 13 (14%) being inadequate (P=0.50). Of the 13 inadequate Endosee^® hysteroscopies, 4 (31%) were due to visualization, 4 (31%) to patient intolerance, 3 (23%) to cervical stenosis, and 2 (15%) to a combination of these factors. Of the 8 inadequate TrophyScope^® hysteroscopies, 7 (87%) were due to patient intolerance and 1 (13%) to cervical stenosis. Of the 150 adequate office procedures performed, 52 cases underwent subsequent procedures in the operating room (OR). Of these, 26 (84%) of 31 Endosee^® cases and 18 (86%) of 21 TrophyScope^® cases were in agreement with OR procedure findings. A subgroup analysis comparing mean pain levels did not significantly differ between the two hysteroscopes.

CONCLUSIONS

There was no difference in accuracy with OR pathologic diagnoses, adequacy of procedure, and reported pain scores when comparing the TrophyScope® and Endosee® in this prospective cohort. Larger studies are needed to confirm the sensitivity, and specificity for these newer, disposable office hysteroscopic devices.

Cost-effectiveness of office hysteroscopy for abnormal uterine bleeding

Background and Objectives:

Office diagnostic hysteroscopy allows physicians to directly view the endometrial cavity, tubal ostia, and endocervical canal without taking the patient to the operating room (OR). We sought to determine whether office hysteroscopy performed to evaluate abnormal uterine bleeding decreases the need for hysteroscopy performed in the OR and the associated financial and risk implications.

Methods:

One hundred thirty patients who underwent office diagnostic hysteroscopy between January 2009 and March 2012 at 2 outpatient clinics in an academic university setting were identified. Records were reviewed from paper charts and electronic medical records. Hospital charts for patients who required hysteroscopy in the OR were reviewed as well. Charge estimates were obtained from our billing department. These results were analyzed for review of the data.

Results:

Seventy-five of the 130 women who underwent diagnostic office hysteroscopy for abnormal bleeding did not need to undergo hysteroscopy in the OR. This represents estimated savings of $1498 per patient (95% confidence interval, $1051–$1923) in procedure charges. Among the 55 women who underwent OR hysteroscopy, there was 71% agreement between findings on hysteroscopy in the office and in the OR.

Conclusion:

Office hysteroscopy is a useful diagnostic tool that can help decrease the rate of diagnostic hysteroscopy in the OR under anesthesia when used in a select patient population.

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

The objective of this study was to provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning hysteroscopy. Vaginoscopy should be the standard technique for diagnostic hysteroscopy (Grade A) using a miniature (≤3.5mm sheath) (Grade A) rigid hysteroscope (Grade C), using normal saline solution distension medium (Grade C), without any anaesthesia (conscious sedation should not be routinely used), without cervical preparation (Grade B), without vaginal disinfection and without antibiotic prophylaxy (Grade B). Misoprostol (Grade A), vaginal oestrogens (Grade C), or GnRH agonist routine administration is not recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge the air out of the system (Grade A). The uterine cavity distention pressure should be maintained below the mean arterial pressure and below 120mm Hg. The maximum fluid deficit of 2000ml is suggested when using normal saline solution and 1000ml is suggested when using hypotonic solution. When uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury. Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (Grade B). Implementation of this guideline should decrease the prevalence of complications related to hysteroscopy.

[Prevention of the complications related to hysteroscopy: guidelines for clinical practice]

OBJECTIVE

To provide clinical practice guidelines (CPGs) from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning the adverse events related to hysteroscopy.

MATERIALS AND METHODS

Review of literature using following Keywords: hysteroscopy; vaginoscopy; infection; perforation; intrauterine adhesions

RESULTS

Vaginoscopy should be the standard technique for outpatient hysteroscopy (grade A) using a miniature (≤ 3.5mm sheath) (grade A) rigid hysteroscope (grade C), using normal saline solution distension medium (grade C), without any anesthesia (conscious sedation should not be routinely used), without cervical preparation (grade B), without vaginal disinfection and without antibiotic prophylaxy (grade B). Misoprostol (grade A), vaginal estrogens (grade C), or GnRH agonist routine administration is not recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge the air out of the system (grade A). The uterine cavity distention pressure should be maintained below the mean arterial pressure and below 120 mmHg. The maximum fluid deficit of 2000 mL is suggested when using normal saline solution and 1000 mL is suggested when using hypotonic solution. When uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury. Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (grade B).

CONCLUSION

Implementation of this guideline should decrease the prevalence of complications related to office and operative hysteroscopy.

Hysteroscopy without anesthesia: review of recent literature

The need for anesthesia or analgesia for performing hysteroscopy is still matter of debate. Many factors explain the lack of agreement about anesthesia in hysteroscopy depending on the instrumentation, technique employed, need of performing surgical procedure, operator skill and patients' characteristics. Diagnostic minihysteroscopy (3.5 mm or less in size) is less painful and easier to perform than hysteroscopy performed with instruments sized around 5 mm. Thanks to miniaturized instruments, office hysteroscopy allows a growing number of women to be treated in an office setting avoiding the operating room. The main limitation to its widespread use is pain and low patient tolerance. Intrauterine surgical procedures involving only the endometrial mucosa (biopsies, adhesiolisis, cervical and endometrial polyectomies) are not painful. For endometrial polypectomy size of polyps (<2.2m) and duration of the procedure (more than 15 min) are limiting factors. Most literature suggests that office hysteroscopy in experienced hands is a well-tolerated technique and requires the use of analgesics only in selected patients like women with previous caesarean section, history of chronic pelvic pain, anxiety and in menopause.

Development of a thinner and more flexible type of minihysteroscope with a controlled 90-degree bendable tip for vision-guided endometrium biopsy

STUDY OBJECTIVE

Evaluation of the uterine cavity is limited with rigid 5-mm hysteroscopes because of the need for cervical dilatation, reduced movements inside the uterus, and no option for vision-guided biopsy. In cooperation with PolyDiagnost GmbH, Pfaffenhofen, Germany, a new type of flexible minihysteroscope with bendable tip was developed and evaluated.

DESIGN

Prospective and parallel observational interindividual evaluation of flexible minihysteroscope and standard hysteroscope for diagnostic hysteroscopy (Canadian Task Force classification II-3).

SETTING

Obstetrics and gynecology department of a university clinic.

PATIENTS

Nine women, average age 65.0 years (range 46-89 years), with indications for diagnostic hysteroscopy.

INTERVENTIONS

After defining requirements, a novel, thinner, and more flexible minihysteroscope, 18-cm long with a 2.67-mm outer diameter, was developed with straight zero-degree scope, 70-degree vision field, and 6000-pixel resolution. Two working channels, 1.2 mm and 0.55 mm, allow suction-irrigation and introduction of a 1.0-mm biopsy forceps or cytology brush. The tip of the instrument is 90-degree stageless bendable to both sides. Diagnostic hysteroscopy was performed with flexible minihysteroscope followed by standard rigid hysteroscopy to verify results.

MEASUREMENTS AND MAIN RESULTS

From July 2003 through March 2004, both procedures were performed in nine patients with identical visual and histologic results. No complications occurred. No cervix-dilating instruments were necessary for introduction of the flexible minihysteroscope. Visualization of the entire uterine cavity is improved with the flexible scope because a bendable tip allows better peripheral vision (e.g., of the openings of the tubes). However, movement of the tip should be performed carefully due to potential risk of uterine perforation.

CONCLUSION

This new flexible minihysteroscope is less invasive compared with standard rigid hysteroscopy, which supports performance of ambulatory hysteroscopy and makes increased movements and vision-guided biopsy inside the uterine cavity possible.