Complications of Hysteroscopic and Uterine Resectoscopic Surgery

Addition of operative hysteroscopy to vacuum aspiration for the management of early pregnancy loss after in vitro fertilization

OBJECTIVE

To investigate whether operative hysteroscopy in addition to vacuum aspiration for the management of early pregnancy loss effectively increases the success rate of subsequent frozen embryo transfer.

DESIGN

Propensity score-matched cohort study.

SETTING

Academic hospital.

PATIENT(S)

Women with a miscarriage at 5-16 gestational weeks during an in vitro fertilization cycle in Peking University Third Hospital from 2015 to 2022.

INTERVENTION(S)

Hysteroscopy plus vacuum aspiration vs. conventional vacuum aspiration.

MAIN OUTCOME MEASURE(S)

Live birth rate in the subsequent frozen embryo transfer.

RESULT(S)

A total of 347 women who underwent vacuum aspiration plus hysteroscopy and 2,562 women who underwent conventional vacuum aspiration were included in the analysis. After propensity score matching (1:1 ratio), 325 women were included in each group. Compared with women who underwent vacuum aspiration, those who underwent vacuum aspiration plus hysteroscopy were associated with a lower rate of live birth in the propensity score-based matched cohort (22% vs. 30%; adjusted odds ratio, 0.68 [0.47-0.97]). Biochemical, clinical, and multiple pregnancy rates were not significantly different, as was the miscarriage rate. In the overall cohort, 11 women experienced surgery reintervention in the vacuum aspiration group (0.4%), whereas none required surgery reintervention in the vacuum aspiration plus hysteroscopy group.

CONCLUSION(S)

Women who underwent vacuum aspiration plus hysteroscopy may be associated with lower rates of live birth than those who underwent vacuum aspiration. Further studies are necessary to establish this relationship definitively.

Paradoxical air embolism in patients undergoing hysteroscopic surgery for cesarean scar pregnancy: A case report and review of the literatures

Cesarean scar pregnancy cases who undergo hysteroscopic suction aspiration could be at higher risk of air emboli due to dilated, low-resistant, high-velocity blood vessels.

Factors Associated with the Complications of Hysteroscopic Myomectomy

OBJECTIVE

 To evaluate the factors associated with complete myomectomy in a single surgical procedure and the aspects related to the early complications.

METHODS

 A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure.

RESULTS

 We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French), most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR]: 0.97; 95% confidence interval [95%CI]: 0.96-0.98) and the classification 0 of the fibroid according to the FIGO (PR: 2.04; 95%CI: 1.18-3.52). We observed early complications in 13.01% of the hysteroscopic procedures (4.44% presented excessive bleeding during the procedure, 4.14%, uterine perforation, 2.66%, false route, 1.78%, fluid overload, 0.59%, exploratory laparotomy, and 0.3%, postoperative infection). The only independent factor associated with the occurrence of early complications was incomplete myomectomy (PR: 2.77; 95%CI: 1.43-5.38).

CONCLUSIONS

 Our results show that hysteroscopic myomectomy may result in up to 13% of complications, and the chance of complete resection is greater in small and completely intracavitary fibroids; women with larger fibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

Likelihood of Accomplishing an In-Patient Hysteroscopic Myomectomy in a One-Step Procedure: A Systematic Review and Meta-Analysis

PURPOSE

To assess the feasibility rate of one-step hysteroscopic myomectomy according to the technique adopted.

METHODS

In July 2016, PubMed, ClinicalTrials.gov, SCOPUS, Scielo, and AJOL databases were used for searching references. Series of in-patient hysteroscopic myomectomies reporting success rate in only one-step procedure, categorization of submucous fibroids, explanation of the surgical technique, and description of patients were considered eligible for meta-analysis (retrospective, prospective randomized studies). Two authors extracted the data. Rate of myomectomies accomplished in only a surgical step and rate of intraoperative complications were extracted per protocol. A modified GRADE score was used for quality assessment. Random-effect models were already assumed. Mean rates were compared among subgroups.

RESULTS

One thousand two hundred and fifty-seven studies were screened and 241 of these were read for eligibility. Seventy-eight series were included in qualitative synthesis and 24 series were included in quantitative synthesis. Wide heterogeneity was found. In series with <50% of G2 myomas treated, the slicing technique feasibility rate was 86.5% while techniques for enucleating the deep portion of the myomas showed a feasibility rate of 92.3% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (p < 0.001). In series with ≥50% of G2 myomas treated, the slicing technique feasibility rate was 70.6% while techniques for enucleating the deep portion of myomas showed a feasibility rate of 88.4% (.

CONCLUSION

In case of submucous myomas with intramural development, the slicing technique was correlated with a lower rate of in-patient hysteroscopic myomectomies accomplished in a one-step procedure and a higher complications rate.

Manual versus Pump Infusion of Distending Media for Hysteroscopic Procedures: A Randomized Controlled Trial

Fluid overload is a potential complication of hysteroscopic procedures with the possibility of dangerous electrolyte changes. This prospective randomized controlled trial aimed to compare perioperative outcomes and changes in electrolytes after hysteroscopic procedures between the manual infusion (MI) and the pump infusion (PI) methods for distending media infusion. One hundred consecutive women who had hysteroscopic procedures between December 2013 and February 2017 were recruited and randomly allocated to either the MI or PI group. The PI group was associated with an increased volume of infused fluid and collected fluid compared with the volumes of the MI group. Almost all serum electrolyte levels differed significantly between the baseline and postoperative values in both groups; however, no significant differences were noted between the groups. The change in potassium level was positively correlated with the volume of fluid deficit (Spearman's rho = 0.24, P = 0.03), whereas the change in calcium level was negatively correlated with the volume of fluid deficit (Spearman's rho = -0.26, P = 0.046). With no between-group differences in the changes in the other perioperative parameters and electrolytes, the MI method can be a good alternative for delivering distending media for hysteroscopic procedures.

Uterine rupture in pregnancy subsequent to hysteroscopic surgery: A case series

Uterine rupture during pregnancy is associated with high mortality and morbidity rates in both the fetus and the mother. Hysteroscopic surgeries such as myomectomy and septum resection are known risk factors for uterine rupture in pregnancy following the operation. We present four infertile patients who were admitted to Kocaeli Medical Park Hospital between February 2014 and November 2016. Three of the patients underwent hysteroscopic septum resection without complication and one had hysteroscopic myomectomy and a 7-8 mm sized rupture was detected. All of the patients became pregnant in less than a year after the operations. The first three patients had uterine rupture at 22^nd, 38^th, and 10^th week, which is the earliest rupture in the literature. The last patient had an uneventful pregnancy and the rupture was observed during cesarean section. A short interval between hysteroscopy and pregnancy may increase the risk of rupture. It may be possible to become pregnant despite rupture and not have any problems during the entire pregnancy.

Monitoring of Gas Emboli During Hysteroscopic Surgery: A Prospective Study

OBJECTIVES

Previous studies have demonstrated a high frequency of gas emboli during hysteroscopy, but guidelines for the prevention, early detection, and intervention of gas embolism during hysteroscopic procedures are still lacking. This study aimed to gain a clearer understanding of risk factors and specific signs and symptoms associated with gas emboli.

METHODS

This prospective study enrolled 120 women scheduled for hysteroscopy using 5% glucose as distension medium. The gas bubbles were monitored sequentially in internal iliac vein, common iliac vein, inferior vena cava, superior vena cava, heart, and pulmonary artery under the gray-scale imaging of Doppler ultrasound. The frequency, extent, and the hemodynamic and respiratory effects of gas emboli were evaluated. The interventions and outcomes were recorded. The risk factors associated with gas emboli, and their relationship with the frequency and extent of gas emboli, were assessed.

RESULTS

In our study, evidence of gas emboli under Doppler ultrasound monitoring was observed in 44 (36.7%) patients. The operation was continued and finished as soon as possible for patients presenting with stable vital signs or transient hemodynamic and respiratory changes, which resolved spontaneously without intervention. The operation was paused for patients presenting with significant hemodynamic changes or loss of consciousness, and the operation was resumed shortly after resumption of stable vital signs following symptomatic treatment. All patients in our study finished the operation and recovered without developing serious complications. Data analysis showed prolonged procedure duration and increased bleeding volume were both positively correlated with the frequency and extent of gas emboli.

CONCLUSION

Our study demonstrated a high frequency of gas emboli during hysteroscopy. Doppler ultrasonic monitoring combined with a clearer understanding of specific signs, symptoms, and risk factors will facilitate early detection and intervention of gas emboli during hysteroscopy.

Training and Assessment of Hysteroscopic Skills: A Systematic Review

OBJECTIVE

The aim of this systematic review was to identify studies on hysteroscopic training and assessment.

DESIGN

PubMed, Excerpta Medica, the Cochrane Library, and Web of Science were searched in January 2015. Manual screening of references and citation tracking were also performed. Studies on hysteroscopic educational interventions were selected without restrictions on study design, populations, language, or publication year. A qualitative data synthesis including the setting, study participants, training model, training characteristics, hysteroscopic skills, assessment parameters, and study outcomes was performed by 2 authors working independently. Effect sizes were calculated when possible. Overall, 2 raters independently evaluated sources of validity evidence supporting the outcomes of the hysteroscopy assessment tools.

RESULTS

A total of 25 studies on hysteroscopy training were identified, of which 23 were performed in simulated settings. Overall, 10 studies used virtual-reality simulators and reported effect sizes for technical skills ranging from 0.31 to 2.65; 12 used inanimate models and reported effect sizes for technical skills ranging from 0.35 to 3.19. One study involved live animal models; 2 studies were performed in clinical settings. The validity evidence supporting the assessment tools used was low. Consensus between the 2 raters on the reported validity evidence was high (94%).

CONCLUSIONS

This systematic review demonstrated large variations in the effect of different tools for hysteroscopy training. The validity evidence supporting the assessment of hysteroscopic skills was limited.

Morcellation complications: From direct trauma to inoculation

Morcellation is the fragmentation of tissue to facilitate removal of the specimen through small incision in minimally invasive surgery. This technique is not unique to gynecology and is used in general surgery with the goal of improved surgical outcomes including decreased pain, cost, hospital length of stay, and rapid return to normal activities and work. Gynecologic laparoscopic power morcellation (LPM) has come under increased scrutiny over the last 2 years due to widespread attention to a known but rare complication, an unanticipated dissemination of malignancy, namely occult uterine leiomyosarcoma. This chapter focuses on complications associated with gynecologic tissue morcellation from inoculation of benign or malignant tissue fragments within the peritoneal cavity and direct trauma from morcellation techniques. We also include a review of the various morcellation techniques from knife to electrical and the use of intraperitoneal specimen containment systems.

Pregnancy Outcome after Office Microhysteroscopy in Women with Unexplained Infertility

Background

Hysteroscopy offers diagnostic accuracy and the ability to treat uterine pathology. The current study aimed to review the findings and feasibility of the proposed office-based diagnostic and operative microhysteroscopy in previously diagnosed wom- en with unexplained infertility and to evaluate the post-microhysteroscopic pregnancy outcome in a-year follow-up period.

Materials and Methods

This prospective controlled study was conducted between 2006 and 2013. Two hundreds women with unexplained infertility were randomized into two groups: A. study group including 100 women recruited for office micohysteroscopic session and B. control group including 100 without the proposed microhysteroscopic intervention. A malleable fiberoptic 2-mm, 0 and 30 degrees angled hysteroscopy along with an operative channel for grasping forceps, scissors, or coaxial bipolar electrode were used for both diagnostic and operative indications. The findings, complications, and patient tolerance were recorded. A-year follow-up of pregnancy outcome for both groups was also performed.

Results

Seventy cases (70%) of patients had a normal uterine cavity. Twenty wom- en (20%) had endometrial polyps. Other pathology included submucous myomas in 3 cases (3%), intrauterine adhesions in 3 cases (3%), polypoid endometrium in 3 cases (3%), and bicornuate uterus in one case (1%). The pathological findings were treated in all patients without complication. Also a-year follow-up of the to- tal developing cumulative pregnancy rate (CPR) was evaluated in groups A and B (control). Group A revealed the total CPR of 28.5%, among which 25% in women without pathology, 40% in women with endometrial polyps, 23% in women with adhesions, 33% in women with polypoid endometrium, and 21% in those with bi- cornuate uterus. However, A-year follow-up of spontaneous pregnancy outcome in group B showed a total CPR of 15%.

Conclusion

Women tolerance, safety, and feasibility of simultaneous operative correc- tion make the proposed office microhysteroscopy an ideal and routine procedure in order to diagnose and to treat missed intrauterine abnormalities, especially in cases with un- explained infertility, with additional improvement of the pregnancy outcome after the procedure.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Hysteroscopic septal resection using unipolar resectoscope versus bipolar resectoscope: Prospective, randomized study

AIM

To compare the operation and reproductive outcome of hysteroscopic septal resection using unipolar resectoscope verses bipolar resectoscope.

METHODS

In this prospective randomized study, 70 women underwent hysteroscopic septal resection using either unipolar resectoscope or bipolar resectoscope. Intraoperative parameters (operation time, fluid deficit and complications) and pre- and postoperative serum sodium levels were compared between the two groups. A second-look hysteroscopy was performed after 6 weeks. All pregnancies occurring during the follow-up period were recorded.

RESULTS

There was no statistically significant difference between the two groups in terms of operation parameters and second-look hysteroscopy findings. Six patients in the unipolar group were found to have hyponatremia in the postoperative period compared to none in the bipolar group (P = 0.025). Regarding reproductive outcome, the difference between the two groups was not significant.

CONCLUSION

The use of bipolar resectoscope is associated with lesser risk of hyponatremia compared to unipolar resectoscope. Bipolar resectoscopy is a safe alternative to unipolar resectoscopy with similar reproductive outcome.

Advanced hysteroscopic surgery training

Hysteroscopic surgery is pivotal in management of many gynecological pathologies. The skills required for performing advanced hysteroscopic surgery (AHS), eg, transcervical hysteroscopic endometrial resection (TCRE), hysteroscopic polypectomy and myomectomy in the management of menorrhagia, hysteroscopic septulysis in fertility-related gynecological problems and hysteroscopic removal of chronically retained products of conception and excision of intramural ectopic pregnancy ought to be practiced by contemporary gynecological surgeons in their day-to-day clinical practice. AHS is a minimally invasive procedure that preserves the uterus in most cases. Whilst the outcome is of paramount importance, proper training should be adopted and followed through so that doctors, nurses, and institutions may deliver the highest standard of patient care.

Carboxyhaemoglobin formation and ECG changes during hysteroscopic surgery, transurethral prostatectomy and tonsillectomy using bipolar diathermy

Diathermy is known to produce a mixture of waste products including carbon monoxide. During transcervical hysteroscopic surgery, carbon monoxide might enter the circulation leading to the formation of carboxyhaemoglobin. In 20 patients scheduled for transcervical hysteroscopic resection of myoma or endometrium, carboxyhaemoglobin was measured before and at the end of the surgical procedure, and compared with levels measured in 20 patients during transurethral prostatectomy, and in 20 patients during tonsillectomy. Haemodynamic data, including ST-segment changes, were recorded. Levels of carboxyhaemoglobin increased significantly during hysteroscopic surgery from median (IQR [range]) 1.0% (0.7-1.4 [0.5-4.9])% to 3.5% (2.0-6.1 [1.3-10.3]%, p < 0.001), compared with levels during prostatectomy or tonsillectomy. Significant ST-segment changes were observed in 50% of the patients during hysteroscopic surgery. Significant correlations were observed between the increase in carboxyhaemoglobin and the maximum ST-segment change (ρ = -0.707, p < 0.01), between the increase in carboxyhaemoglobin and intravasation (ρ = 0.625; p < 0.01), and between intravasation and the maximum ST-segment change (ρ = -0.761; p < 0.01). The increased carboxyhaemoglobin levels during hysteroscopic surgery appear to be related to the amount of intravasation and this could potentially be a contributing factor to the observed ST-segment changes.

Operative hysteroscopy intravascular absorption syndrome: A bolt from the blue

Operative hysteroscopy has emerged as an effective alternative to hysterectomy and has become standard surgical treatment for varied gynaecological conditions like abnormal uterine bleeding and uterine myomas. This procedure requires distention of the uterine cavity for adequate visualization of the operative field. 1.5% glycine is a widely used distention medium because it has good optical properties and is non-conductive. However, the intraoperative absorption of this electrolyte-free fluid can cause hyponatraemia, hypoosmolality, hyperglycinaemia and volume overload, including pulmonary oedema. We report a case of operative hysteroscopy intravascular absorption (OHIA) syndrome, presenting abruptly during hysteroscopic myomectomy, employing 1.5% glycine as the fluid distention medium. Successful management of the case and prevention strategies are discussed.

Gas embolism during hysteroscopic surgery using bipolar or monopolar diathermia: a randomized controlled trial

OBJECTIVE

The objective of the study was to determine the incidence and amount of gas embolism during hysteroscopic surgery using either monopolar or bipolar diathermia and to investigate the relationship between the severity of gas embolism and the amount of intravasation of distension fluid.

STUDY DESIGN

This was a randomized, observer-blinded trial. Fifty patients, scheduled for hysteroscopic surgery, were assigned to either monopolar or bipolar diathermia. Transesophageal echocardiography was used to detect and classify gas embolism (grade 0-IV). Intravasation of distension fluid was measured.

RESULTS

Venous gas embolism was observed in all but 1 patient. A higher incidence of more extensive (grade IV) was seen during bipolar diathermia (42% vs 13%; P = .031). Paradoxical embolism was observed in 2 patients. When intravasation exceeded 1000 mL, significantly more grade IV venous gas embolism was seen (P = .049).

CONCLUSION

During hysteroscopic surgery, gas embolism was equally observed irrespective of the type of diathermia. However, more extensive embolism was observed when intravasation of distension fluid exceeded 1 L. These results question the acceptance of up to 2500 mL intravasation of distension fluid if bipolar diathermia is used.