Hemorrhage risk during operative hysteroscopy

Does “no-touch” technique hysteroscopy increase the risk of infection?

Objective:

Today, thanks to its many advantages, hysteroscopy with a vaginoscopic approach (no-touch) is increasingly being used more in outpatient diagnoses and treatments. However, there are concerns that the “no-touch” technique increases ascending genital tract infections since a speculum is not inserted, and disinfection of the cervix cannot achieve.

Materials and Methods:

Between 2011 and 2017, 302 patients who underwent office hysteroscopy with the vaginoscopic approach (group 1) and 254 patients who underwent hysteroscopy with the standard method under anesthesia in the operating room (group 2) were compared in terms of early complications (within two weeks postoperatively). The primary outcome was early postoperative infection, and the secondary outcome was other early complications, such as bleeding and rupture.

Results:

In this study, the success rate of hysteroscopy with the vaginoscopic approach was 96.4%. According to the visual analog scale scoring system, 88.7% of the patients described mild-to-moderate pain. When group 1 and 2 were compared in terms of postoperative infection (3% and 2.4%, respectively) and other early complication rates (0% and 0.8%, respectively), no statistically significant difference was found (p>0.05).

Conclusion:

Hysteroscopy with a vaginoscopic approach continues to be the gold standard method that is safe and well-tolerated by patients.

Thrombotic microangiopathy following a minor gynaecological procedure in the setting of endometrial cancer: a case report

Hysteroscopy dilatation and curettage is a common minor gynaecological procedure utilised for diagnostic or therapeutic purposes. A 62-year-old woman underwent a hysteroscopy, dilatation and curettage for investigation of prolonged post-menopausal bleeding. Unexpected uterine haemorrhage was encountered without evidence of uterine perforation causing haemodynamic instability. A thrombotic microangiopathy was triggered, leading to microangiopathic haemolytic anaemia, thrombocytopaenia and evidence of micro-thrombosis causing stroke and end-organ dysfunction, including acute renal failure. The histopathology confirmed stage 1 endometrioid adenocarcinoma. This is the first case report of a thrombotic microangiopathy leading to microangiopathic haemolytic anaemia in a patient with endometrioid adenocarcinoma FIGO grade 1, stage 1B following a minor gynaecological procedure.

•

Unexpected haemorrhage followed diagnostic hysteroscopy dilatation and curettage.

•

Thrombotic microangiopathy occurred in the context of stage 1 endometrial cancer.

•

Minor gynaecological surgery resulted in the development of thrombotic microangiopathy.

Complication Rates after Endometrial Ablation in Ontario: A Cohort Analysis of 76 446 Patients

STUDY OBJECTIVES

Endometrial ablation (EA) is an alternative to hysterectomy for the management of heavy menstrual bleeding; however, EA is not without risk. Our objective was to determine complication rates in women undergoing EA in the province of Ontario over a 15-year time period. The primary outcome was a composite of multiple complications within 30 to 180 days of surgery. The secondary outcomes included mortality, length of hospital stay, hospital readmission, and emergency department visit within 30 days of discharge.

DESIGN

Retrospective cohort study using Cochran-Armitage test for trend.

SETTING

Administrative data from the Canadian province of Ontario, assessing patients undergoing surgery in a publicly funded healthcare system.

PATIENTS

Women in Ontario undergoing a primary EA over a 15-year time period.

INTERVENTIONS

The intervention was a primary EA.

MEASUREMENTS AND MAIN RESULTS

We assessed for genitourinary complication, fistula, gastrointestinal complication, pain, control of bleeding, blood transfusion, infectious complication, venous thromboembolism, fluid overload, thermal injury, and other injuries related to surgery. The secondary outcomes included 1-month and 6-month mortality, length of hospital stay, hospital readmission, and emergency department visit within 30 days of discharge. A total of 76 446 primary EAs were evaluated from 2002 to 2017, with the number of EAs per year increasing over the study period by 47%. Complications were seen in 4.8% of the cohort, with the complication rate being relatively stable over time. Although 6.2% of the cohort re-presented to the emergency department, <1% required readmission, and <0.05% died within 180 days. On multivariable analysis, the risk of complications increased with a preoperative diagnosis of other than bleeding (odds ratio [OR] 2.89; 95% confidence interval [CI], 2.61-3.21; p <.001), previous abdominal surgery (OR 1.42; 95% CI, 1.28-1.56; p <.001), and American Society of Anesthesiologists score 3+ (OR 1.37; 95% CI, 1.27-1.48; p <.001).

CONCLUSION

Primary EA is associated with complications in <5% of the patients, with serious complications infrequent.

The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion, Number 800

This Committee Opinion provides guidance on the current uses of hysteroscopy in the office and the operating room for the diagnosis and treatment of intrauterine pathology and the potential associated complications. General considerations for the use of diagnostic and operative hysteroscopy include managing distending media, timing for optimal visualization, and cervical preparations. In premenopausal women with regular menstrual cycles, the optimal timing for diagnostic hysteroscopy is during the follicular phase of the menstrual cycle after menstruation. Pregnancy should be reasonably excluded before performing hysteroscopy. There is insufficient evidence to recommend routine cervical ripening before diagnostic or operative hysteroscopy, but it may be considered for those patients at higher risk of cervical stenosis or increased pain with the surgical procedure. In randomized trials, patients reported a preference for office-based hysteroscopy, and office-based procedures are associated with higher patient satisfaction and faster recovery when compared with hospital-based operative hysteroscopy. Other potential benefits of office hysteroscopy include patient and physician convenience, avoidance of general anesthesia, less patient anxiety related to familiarity with the office setting, cost effectiveness, and more efficient use of the operating room for more complex hysteroscopic cases. Appropriate patient selection for office-based hysteroscopic procedures for women with known uterine pathology relies on thorough knowledge and understanding of the target pathology, size of the lesion, depth of penetration of the lesion, patient willingness to undergo an office-based procedure, physician skills and expertise, assessment of patient comorbidities, and availability of proper equipment and patient support. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL) agree that vaginoscopy may be considered when performing office hysteroscopy because studies have shown that it can significantly reduce procedural pain with similar efficacy. The office hysteroscopy analgesia regimens commonly described in the literature include a single agent or a combination of multiple agents, including a topical anesthetic, a nonsteroidal antiinflammatory drug, acetaminophen, a benzodiazepine, an opiate, and an intracervical or paracervical block, or both. Based on the currently available evidence, there is no clinically significant difference in safety or effectiveness of these regimens for pain management when compared to each other or placebo. Patient safety and comfort must be prioritized when performing office hysteroscopic procedures. Patients have the right to expect the same level of patient safety as is present in the hospital or ambulatory surgery setting.

Complications of Hysteroscopic and Uterine Resectoscopic Surgery

Adverse events associated with hysteroscopic procedures are generally rare, but, with increasing operative complexity, it is now apparent that they are experienced more often. There exists a spectrum of complications that relate to generic components of procedures, such as patient positioning, anesthesia, and analgesia, to a number that are specific to intraluminal endoscopic surgery that largely comprise perforation and injuries to surrounding structures and blood vessels. Whereas a number of endoscopic procedures require the use of distending media, the response of premenopausal women to excessive absorption of nonionic fluids used for hysteroscopy is somewhat unique, and deserves special attention on the part the surgeon. There is also an increasing awareness of uncommon but problematic sequelae related to the use of monopolar radiofrequency uterine resectoscopes that involve thermal injury to the vulva and vagina. Furthermore, the uterus that has previously undergone hysteroscopic surgery may behave in unusual ways, at least in premenopausal women who experience menstruation or who become pregnant. Fortunately, better understanding of the mechanisms involved in these adverse events, as well as the use or development of a number of innovative devices, have collectively provided the opportunity to perform hysteroscopic and resectoscopic surgery in a manner that minimizes risk to the patient.

Is Cold Loop Hysteroscopic Myomectomy a Safe and Effective Technique for the Treatment of Submucous Myomas With Intramural Development? A Series of 1434 Surgical Procedures

STUDY OBJECTIVE

To assess the safety and efficacy of cold loop hysteroscopic myomectomy in a large series of cases.

DESIGN

Retrospective study (Canadian Task Force Classification III).

SETTING

Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy.

PATIENTS

A total of 1215 patients with 1 or more G1-G2 submucous myomas.

INTERVENTION

Cold loop hysteroscopic myomectomy.

MEASUREMENT AND MAIN RESULTS

A total of 1690 myomas were removed. A minimum of 1 to a maximum of 5 fibroids for each surgical procedure were totally removed. Out of 1215 patients, 1017 (83.7%) were treated with a single surgical procedure. Twelve intraoperative complications occurred (0.84%). No cases of uterine perforation with the thermal loop or clinical intravasation syndrome were reported.

CONCLUSION

Cold loop hysteroscopic myomectomy seems to represent a safe and effective procedure for the removal of submucous myomas with intramural development, while at the same time respecting the anatomic and functional integrity of the myometrium. The use of a cold loop in resectoscopic myomectomy is associated with a low rate of minor intraoperative complications and an absence of major complications. This could be of primary relevance with a view to fertility and future pregnancies.

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.

Hysteroscopic enucleation in toto of submucous type 2 myomas: long-term follow-up in women affected by menorrhagia

STUDY OBJECTIVE

To evaluate long-term efficacy of type 2 myoma enucleation in toto.

DESIGN

Longitudinal retrospective study (Canadian Task Force classification II-2).

SETTING

University obstetrics and gynecology clinic.

PATIENTS

One hundred twelve women with menorrhagia and at least 1 type 2 submucous myoma who underwent hysteroscopic myoma enucleation in toto.

INTERVENTION

Clinical long-term follow-up.

MEASUREMENTS AND MAIN RESULTS

Success of the procedure and influence of myoma characteristics on recurrence of menorrhagia were evaluated. Mean (SD) follow-up was 58.4 (19.1) months. The success of the procedure was 88.4% (99 patients). Seventeen patients (15.2%) underwent a 2-step procedure. Among patients with relapsed menorrhagia, 10 (8.9%) underwent a repeat operation. Statistical analysis showed that number and diameter of myomas did not influence the outcome. Localization in the posterior wall of the uterus, compared with other sites, was associated with a higher percentage of resolution of menstrual symptoms (p = .03). There was no significant relationship between myomas features and risk of symptom recurrence during follow-up. The 2-step myomectomy was performed in patients with myomas >30 mm in diameter (p < .001).

CONCLUSION

Hysteroscopic enucleation in toto of type 2 myomas is a safe and effective technique in long-term management of premenopausal women with menorrhagia.

[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.

Two cases of postmyomectomy pseudoaneurysm treated by transarterial embolization

Pseudoaneurysm resulting from hysteroscopic myomectomy is a rare clinical situation, and interventional radiologists are not traditionally involved in the management. To our knowledge, endovascular treatment of a pseudoaneurysm resulting from hysteroscopic myomectomy has not yet been reported in the English-language literature. Here, two such cases are reported, including one of a woman who later became pregnant. The case is unique because little is known about the influence of unilateral coil embolization of the uterine artery on fertility.

Safety issues of hysteroscopic surgery

The term hysteroscopy is used to determine the procedure during which an endoscopic view of the endometrial cavity is achieved with the help of a type of endoscopic device called "the hysteroscope." Hysteroscopy is used to assist the diagnosis for a series of female pathology. Apart from its diagnostic value, hysteroscopy can also be used for operative procedures including ablation and resection. Both diagnostic and operative hysteroscopy have been used for a number of years and various studies have been published to describe their success and complication rates throughout this period. Diagnostic hysteroscopy is relatively safe, whereas complications occur more frequently when operative hysteroscopy is used. These complications include uterine perforation, hemorrhage, fluid overload, gas embolization, and hyponatremia. The rate in the appearance of these complications is dependent on the type of the hysteroscopic procedure, the distending medium, and the experience of the hysteroscopist. To avoid any problems concerning the application of hysteroscopic procedures, it is important to take the necessary precautions both preoperatively and intraoperatively. For example, the preoperative use of thinning agents of the endometrium and the reduction of the operating time, or the avoidance of cutting too deeply into the myometrium, are some of the parameters to be considered when hysteroscopy is in argument.

Hysteroscopic myomectomy

Hysteroscopic myomectomy is a minimally invasive technique that eliminates the need for a laparotomy and is associated with lower morbidity than abdominal myomectomy. Its beneficial effects are reflected by the improvement in menstrual pattern, fertility rate, and overall patient satisfaction. It is usually performed as outpatient surgery but occasionally requires an overnight stay. Most patients return to full activity within 48 hours. To exploit the full potentials of this procedure, appropriate case selection and surgical expertise are essential. It should be considered as first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids.