Is outpatient hysteroscopy the new gold standard? Results from an 11 year prospective observational study

Outpatient hysteroscopy: Suitable for all? A retrospective cohort study of safety, success and acceptability in Australia

BACKGROUND

In Australia, gynaecologists continue to assess and investigate abnormal uterine bleeding with inpatient hysteroscopy despite evidence validating outpatient hysteroscopy services.

AIM

This retrospective cohort study assessed the safety, success and acceptability of office hysteroscopy in a gynae-oncology rapid-access clinic over six years in Sydney, Australia, and included all women without an age or body mass index (BMI) cut-off using a 'see and treat' concept.

METHODS

A database was created and analysed retrospectively for patients who attended office hysteroscopy service between January 2016 and March 2021 (63 months, 481 eligible). An anonymous modified PAT-32 patient satisfaction questionnaire was also offered to an initial cohort after their procedure to gauge insightful feedback about acceptability.

RESULTS

A total of 92% of patients had successful outpatient hysteroscopic access; 24% of cases required hysteroscopy under general anaesthesia (GA) despite pathology in over 50% of cases; 68% of the total were able to be managed with outpatient hysteroscopy and did not require a follow-up GA hysteroscopy. This paper is also the first of its kind to our knowledge to incorporate patients >65 years, those with a BMI >35 and those with a history of cervical stenosis. This study suggests that age and BMI do not impact the success rate of the procedure.

CONCLUSION

This study demonstrates that outpatient hysteroscopy is an acceptable, safe procedure that is well tolerated by patients. Considering our rapid-access hysteroscopy service allowed 68% of the patient cohort to avoid hysteroscopy under GA, we estimate conservatively ~$63 million per year in Australia could be saved by performing office hysteroscopies.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of whether there is residual polyp tissue after hysteroscopic morcellation at Cam and Sakura City Hospital: a retrospective cohort study

BACKGROUND

In polypectomy with mechanical hysteroscopic morcellators, the tissue removal procedure continues until no polyp tissue remains. The decision that the polypoid tissues were removed completely is made based on visual evaluation. In a situation where the polyp tissue was visually completely removed and no doubt that the polyp has been completely removed, short spindle-like tissue fragments on the polyp floor continue in most patients. There are no studies in the literature on whether visual evaluation provides adequate information at the cellular level in many patients in whom polypoid tissues have been determined to be completely removed. The aim of the present study was to analyze the pathological results of the curettage procedure, which was applied following the completion of polyp removal with operative hysteroscopy, and to evaluate whether there was residual polyp tissue in the short spindle-like tissue fragments that the mechanical hysteroscopic morcellator could not remove. The secondary aims of this study were to compare conventional loop resection hysteroscopy with hysteroscopic morcellation for the removal of endometrial polyps in terms of hemoglobin/hematocrit changes, polypectomy time and the amount of medium deficit.

METHODS

A total of 70 patients with a single pedunculate polypoid image of 1.5-2 cm, which was primarily visualized by office hysteroscopy, were included in the study. Patients who had undergone hysteroscopic polypectomy were divided into two groups according to the surgical device used: the morcellator group (n = 35, Group M) and the resectoscope group (n = 35, Group R). The histopathological results of hysteroscopic specimens and curettage materials of patients who had undergone curettage at the end of operative hysteroscopy were evaluated. In addition, the postoperative 24th hour Hb/HCT decrease amounts in percentage, the polypectomy time which was measured from the start of morcellation, and deficit differences were compared between groups.

RESULTS

In total, 7 patients in the morcellator group had residual polyp tissue detected in the full curettage material. The blood loss was lower in the morcellator group than in the resectoscope group (M, R; (-0.07 ± 0.08), (-0,11 ± 0.06), (p < 0.05), respectively). The deficit value of the morcellator group were higher (M, R; (500 ml), (300 ml), (p < 0.05), respectively). The polypectomy time was shorter in the morcellator group (M, R; mean (2.30 min), (4.6 min), (p < 0.05)).

CONCLUSIONS

Even if the lesion is completely visibly removed during hysteroscopic morcellation, extra caution should be taken regarding the possibility of residual tissue. There is a need for new studies investigating the presence of residual polyp tissue.

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.

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.

Uptake of outpatient hysteroscopy in Australia using Medical Benefits Scheme data: Have we fallen behind?

BACKGROUND

Hysteroscopy is a safe procedure which allows both diagnosis and management of cervical and endometrial pathology. Improving Australian women's access to outpatient hysteroscopy would improve cost efficiency and allow women a quicker recovery, negating the need for a general anaesthetic. Increasing the Medicare renumeration for outpatient hysteroscopy could incentivise provision of outpatient hysteroscopy.

AIM

We sought to review the trend and current uptake of outpatient diagnostic hysteroscopy in Medicare Benefits Scheme (MBS)-funded clinics within Australia.

MATERIALS AND METHODS

A retrospective review of Australian MBS data from 1 January 1993 to 31 December 2020.

RESULTS

Over the past 27 years, 1 319 909 hysteroscopies have been claimed from Medicare in Australia, with 39 958 (3.1%) claimed as an outpatient diagnostic procedure. Australian outpatient diagnostic hysteroscopy MBS item number use peaked in 1994 (5871 cases) representing 18.2% of all hysteroscopies claimed through the MBS that year. Uptake of the outpatient hysteroscopy item number rapidly declined after 1994 and in 2010, it represented 0.8% of all hysteroscopies claimed (426 of 49 618) and has remained below <0.5% from 2010 to 2020.

CONCLUSIONS

The lower Medicare rebate and lack of recognition of the importance of outpatient hysteroscopy has likely been a driving factor in continuing inpatient hysteroscopy. Incentivised government funding has been successfully utilised in the UK to improve outpatient hysteroscopy access. This MBS data suggests that Australia has not progressed in outpatient hysteroscopy access and support a change in the current funding model to assist in supporting the uptake of outpatient access.

Uterine Cavity Parameters Evaluated by Hysteroscopy can Predict the Live Birth Rate For Intrauterine Adhesion Patients

We aim to establish an objective and accurate prediction model by evaluating the uterine cavity and correlate these key factors with the live birth rate after hysteroscopic adhesiolysis (HA). A total of 457 intrauterine adhesions (IUA) patients were retrospectively enrolled in this study. The participants underwent HA and second-look hysteroscopy at the Third Xiangya Hospital of Central South University. Pregnancy outcomes, including spontaneous live births and no live births (miscarriages and infertility), were followed. Clinical parameters, containing the number of visible uterine horns and tubal ostia, the length of the uterine cavity, among others, were measured and analyzed to determine the dominant variables in an attempt to establish the live birth rate, prediction models. Women in the no live birth group were older than that in the live birth group (P = 0.0002, OR = 0.895, 95% CI: 0.844–0.949) and were more likely to be 2 gravidity (P = 0.0136, OR = 2.558, 95% CI: 1.213–5.394). Uterine cavity length in pre-HA hysteroscopy was longer in the live birth group (P = 0.0018, OR = 1.735, 95% CI: 1.227–2.453), and adhesion scores in pre-HA hysteroscopy were more frequently above 6 (P = 0.0252, OR = 0.286, 95% CI: 0.096–0.856) in the no live birth group. During the second-look, hysteroscopy, visible bilateral fallopian tube ostia were more frequently observed in the live birth group (P = 0.0339, OR = 11.76, 95% CI: 1.207–114.611), and adhesion scores were 4–6 (P < 0.0001, OR = 0.032, 95% CI: 0.007–0.146) and above 6 (P < 0.0001, OR = 0.012, 95% CI: 0.002–0.073) in the no live birth group. The areas under the curves (AUCs) of the pre-HA and second-look hysteroscopy prediction models were 0.7552 and 0.8484, respectively. We established an objective and accurate method for evaluating the uterine cavity by hysteroscopy, and second-look hysteroscopy is more valuable than the fist hysteroscopy in predicting the live birth rate following HA. Visible bilateral fallopian tube ostia or adhesion scores were <4 in the second-look hysteroscopy might predict live birth after surgery.

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.

Management of recurrent miscarriages: an overview of current evidence

PURPOSE OF REVIEW

Recurrent miscarriage (RM) or recurrent pregnancy loss (RPL) is defined as the consecutive loss of two or more pregnancies before the age of viability. The exact prevalence of RM is unknown, but it has been reported between 1% and 2%. The objective of this review is to provide a critical summary of the latest evidence for the investigation and management of women with RM.

RECENT FINDINGS

RMs are associated with multiple factors including increased female age and lifestyle habits, as well as genetic factors, hereditary and acquired thrombophilia and infections. Metabolic and endocrine factors, in addition to anatomical causes such as uterine malformations have also been suggested as a causative factors of RM.

SUMMARY

The management of RM would be expected to cause specific, however, in the majority of the cases no cause is identified, and the factors associated with RM may not be causally related with the condition.

Where does the money go to? Cost analysis of gynecological patients with a benign condition

OBJECTIVES

The impact of benign gynecological conditions on life of women and on costs for the society is high. The purpose of this study is to gain knowledge and understanding of costs of the treatment of these disorders in order to be able to improve the clinical care processes, gain insight into feasible savings opportunities and to allocate funds wisely.

METHODS

The healthcare processes of 311 women attending university or community hospitals in the Helsinki and Uusimaa Hospital District between June 2012 and August 2013 due to a benign gynecological condition were followed up for two years and treatment costs analysed.

RESULTS

Total direct hospital costs averaged 689€ at six months and 2194€ at two years. The most expensive treatment was that of uterine fibroids in the short term and that of endometriosis and fibroids later on. Costs did not depend on hospital size. Surgical operations caused nearly half of hospital costs. Productivity loss caused biggest expenses outside of the hospital. LNG-IUD (levonorgestrel-releasing intrauterine device) accounted for the largest pharmaceutical costs for patients. Hospital treatment was associated with a reduced need for outpatient services during follow-up.

CONCLUSIONS

A majority of direct hospital costs arise over time. This stresses the need for prolonged healthcare management. To control costs, the need for repetitive doctors' appointments, monitoring tests, and ward treatments should be carefully evaluated. Procedures not needing an operation theatre (for example hysteroscopy for polypectomy), should be done ambulatorily.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Hysteroscopic approach to uterine cervical canal stenosis

Cervical stenosis is defined as an adhesion process of variable degree, producing narrowing, distortion, or complete obliteration of the cervix. Several techniques have been defined to access to the uterine cavity and nowadays hysteroscopy seems to be the best option. In this manuscript, we review all the hysteroscopic modalities to overcome a cervical stenosis and access to the uterine cavity.

Electronic Continuous Pain Measurement vs Verbal Rating Scale in gynaecology: A prospective cohort study

OBJECTIVE

To compare pain measured with a new electronic device - the Continuous Pain Score Meter (CPSM) - and the Verbal Rating Scale (VRS) during gynaecological procedures in an outpatient setting, and to correlate these outcomes with baseline anxiety and patient (in)tolerance to the procedure.

STUDY DESIGN

This prospective cohort study was undertaken in two centres: a university hospital and a large teaching hospital in The Netherlands. Patients undergoing an outpatient hysteroscopy, colposcopy or ovum pick-up procedure for in-vitro fertilization in one of the two participating hospitals with availability of the CPSM were included. Pain was measured by both the CPSM and the VRS. Patient tolerance to the procedure was reported. Various outcomes of the CPSM were compared with those of the VRS and related to baseline anxiety scores.

RESULTS

Ninety-one of 108 included patients (84 %) used the CPSM correctly during the procedure, and it was possible to analyse the CPSM scores for 87 women (81 %). The CPSM scores were all linearly related to the VRS. The peak pain score on the CPSM (CPSM-PPS) had the strongest correlation with the VRS score for all three procedures. Higher CPSM-PPS was related to patient (in)tolerance to the procedure (p = 0.03-0.002). Anxiety at baseline was not correlated with pain perception, except for VRS during colposcopy (r = 0.39, p = 0.016).

CONCLUSION

The majority of patients were able to use the CPSM correctly, resulting in detailed information on pain perception for each individual pain stimulus during three outpatient gynaecological procedures. The CPSM-PPS had the strongest correlation with the VRS score and patient (in)tolerance to the procedure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

A small dose of dezocine suppresses remifentanil-induced cough in general anesthesia induction: a prospective, randomized, controlled study

Background

The aim of this prospective randomized controlled study was to evaluate whether pretreatment with a small dose of dezocine could prevent remifentanil-induced cough in general anesthesia induction.

Trial design

a prospective, randomized, controlled study.

Methods

A total of 210 patients receiving elective operative hysteroscopy from December 2018 to April 2019 were enrolled in the present study. They were randomly equally separated into dezocine group (n = 105) and control group (n = 105). Patients were intravenously pre-administrated with dezocine 0.03 mg/kg (diluted to 5 mL) or the same volume of normal saline 1 min prior to remifentanil infusion. One minute later, intravenous injection of propofol 1.5 mg/kg and cisatracurium 0.1 mg/kg were given to all patients for induction of general anesthesia. The counts of coughs occurred during the anesthesia induction period were recorded and the severity of cough was scaled.

Results

There were 7 cases of mild cough in dezocine group and 18 cases of mild cough, 12 cases of moderate cough and 4 cases of severe cough in control group. The incidence rate of cough was significantly lower and the severity of cough was obviously relieved in dezocine group compared to control group (6.67% vs. 32.38%, P <  0.001). The two groups were not significantly different in heart rate and mean arterial pressure before the induction, before and after the intubation, and in operating time and postoperative visual analog scale pain scores.

Conclusion

This study recommends the efficacy and safety of a pretreatment with a small dose of dezocine in reducing remifentanil-induced cough during general anesthesia.

Trial Registration

ChiCTR2000032035.

Date of registration: Retrospectively registered on 2020/04/18.

Introduction of the MyoSureLITE in an established outpatient hysteroscopy clinic

BACKGROUND

Endometrial polyps are a common cause of abnormal uterine bleeding. The MyoSureLITE intrauterine morcellation device is effective at resecting endometrial polyps; however, its use in the outpatient setting requires appraisal.

AIM

To assess the feasibility, utility, acceptability and costs associated with introduction of the MyoSureLITE into an established outpatient hysteroscopy (OPH) clinic.

MATERIAL AND METHODS

A prospective clinical database from a tertiary Melbourne hospital was analysed from 1 July 2015 to 30 June 2018. Three 12-month time periods were compared: pre-introduction and trial phase, early use, and established use of the MyoSureLITE. Wait times, patient acceptability, second OPH bookings and procedure costs were measured.

RESULTS

Eight hundred and seventy-one women underwent OPH during the study period, with 238 (27.3%) women presenting with endometrial polyp(s). At each timepoint, 78.5, 25 and 6.3% of women required rebooking for a subsequent hysteroscopy for pathology otherwise suitable for MyoSureLITE resection. Introduction of the MyoSureLITE avoided a subsequent procedure for 4, 60 and 69 women respectively for each year of use, with potentially reduced treatment costs for the institution. Median (IQR) wait time for definitive treatment of intrauterine pathology was 56 (24-84) days at time-period 1, decreasing to 0 (0-0) days during time-period 3, (P < 0.001); 87.6% would undergo OPH again.

CONCLUSIONS

Routine use of the MyoSureLITE is effective, feasible, and acceptable to women. Provision of this device in outpatient service allows a 'see-and-treat' model, saving theatre time and treatment costs, facilitating a more direct throughput from presentation to treatment.

Evaluation and ranking of different interventions for pain relief during outpatient hysteroscopy: A systematic review and network meta-analysis

AIM

To identify the highest-ranked pharmacological and nonpharmacological interventions for pain relief during outpatient hysteroscopy.

METHODS

We conducted an online bibliographic search in different databases from inception till July 2019. We included randomized controlled trials assessing effect of pharmacological and nonpharmacological interventions on pain relief during outpatient hysteroscopy. Our main outcomes were pain scores at different endpoints of the procedure. We applied this network meta-analysis based on the frequentist approach using statistical package 'netmeta' (version 1.0-1) in R.

RESULTS

The review included 39 randomized controlled trials (Women n = 3964). Misoprostol plus intracervical block anesthesia (mean difference [MD] = -3.32, 95% confidence interval [CI] [-6.06, -0.59]), misoprostol (MD = -1.92, 95% CI [-3.04, -0.81]) and IV analgesia (MD = -2.01, 95% CI [-3.27, -0.25]) were effective in reducing pain during the procedure compared to placebo. Ranking probability showed that misoprostol plus intracervical block anesthesia was the highest ranked pharmacological treatment for pain relief during the procedure (P score = 0.92) followed by misoprostol alone (P score = 0.78), and IV analgesia (P score = 0.76). Regarding nonpharmacological treatments, transcutaneous electrical nerve stimulation (TENS) showed a significant pain reduction compared to placebo (MD = -1.80, 95% CI [-3.31, -0.29]). TENS ranked as the best nonpharmacological treatment (P score = 0.80) followed by CO₂ distention (P score = 0.65) and bladder distention (P score = 0.60).

CONCLUSION

Combination of misoprostol plus local anesthesia appears to be the most effective pharmacological approach for pain reduction during and after outpatient hysteroscopy. Nonpharmacological approaches as TENS and bladder distention showed considerable efficacy but should be further investigated.

Failed diagnostic hysteroscopy: Analysis of 62 cases

OBJECTIVE

The aim of the presented study is to improve the office hysteroscopy success rate identifying some of the factors associated to an unsuccessful procedure. Moreover it would highlight the importance of an adequate patients follow up after office hysteroscopy failure enlightening the uterine pathologies missed at the first attempt.

STUDYDESIGN

This is a retrospective observational study. The Authors reviewed the medical records related to 516 office hysteroscopies performed from January 2016 to November 2018, extrapolating the data from the failed hysteroscopies occurred during this period. After the procedure failure all patients were offered to repeat the hysteroscopy under regional anesthesia in order to identify and treat uterine pathologies. Those patients, who declined to repeat the procedure, received an appropriate follow up. Each failure case is correlated with patient clinical characteristics, indications to hysteroscopy, risk factors presence, hysteroscopy patient compliance, pathology result and patient follow up.

RESULTS

The presented study shows an office hysteroscopy failure rate of about 12 %. Severe pain due to cervical stenosis, previous uterine surgery, postmenopausal status and marked uterine ventrifixation/retroflexion, represent the main reason why the procedure was not completed in an office setting. The uterine cavity was subsequently examined in only 26 (42 %) out of 62 patients who reported hysteroscopy failure, mostly repeating the procedure under regional anesthesia (24 cases) or performing vaginal hysterectomy for associated benign gynaecological pathology (2 cases). Endometrial malign pathology (endometrioid carcinoma) was diagnosed in 2 cases of them (7.7 %). Moreover the endometrial cavity remained so far unexplored in 36 (58 %) out of 62 patients, due to the patient refuse to repeat the hysteroscopy under anesthesia.

DISCUSSION AND CONCLUSION

Results of the present study suggest that office hysteroscopy should be sussessful at the first attempt due to the patients' refuse, in majority of cases, to repeat the procedure after a failure. To not repeat the hysteroscopy may lead to lose or delay important diagnosis, such as that of endometrial cancer. In this context, to counsel all patients prior the procedure may singnificanly help to identify those who may benefit of pharmacological cervical softening, local anesthetic injection or small caliber hysteroscopes usage, increasing the procedure success rate.

Low-Dose Ketamine for Outpatient Hysteroscopy: A Prospective, Randomised, Double-Blind Study

Objective

Outpatient hysteroscopy is often accompanied by pain and discomfort along with frequent occurrence of bradycardia and hypotension. This study aimed to observe if intravenous low-dose ketamine reduces the pain scores along with lowering the incidence of bradycardia and hypotension during hysteroscopy.

Methods

This prospective, randomised, double-blind trial was conducted in operating rooms in a tertiary care hospital. In this study, we enrolled 72 patients with American Society of Anesthesiologists status I to II undergoing hysteroscopy. We randomised patients into two groups, and both groups received paracervical block. The control group received intravenous pentazocine and promethazine along with saline infusion. The ketamine group received ketamine infusion (0.75 mg kg⁻¹ bolus followed by infusion at the rate of 10 mcg kg⁻¹ min⁻¹). We analysed visual analogue scale (VAS), rescue analgesic consumption, hemodynamic parameters, lowest recorded heart rate, blood pressure, level of sedation, patient’s comfort, surgeon’s satisfaction and nursing staff’s satisfaction.

Results

Analysis of the data revealed that the pain scores were similar in both the groups (p=0.493, p<0.001). Rescue analgesic was required by 47% patients in control group, compared to only 5.6% patients in ketamine group. Episodes of bradycardia and hypotension were more pronounced in the control group than in the ketamine group [77.4±10.9 vs. 78.4±5.5; 67.6±8 vs. 70.1±6 respectively] (p<0.001). Patient comfort and surgeon’s satisfaction were higher in the ketamine group, but nursing satisfaction was higher in the control group. Disorientation was present in 75% patients in the ketamine group as compared to none in the control group.

Conclusion

We concluded that low-dose ketamine in day-care hysteroscopy is an effective and safe agent.

How the Location of Intracavitary Lesions Influences Pain during Office Hysteroscopy

STUDY OBJECTIVE

To assess how the location of intracavitary lesions during office hysteroscopy influences pain scores.

DESIGN

Cohort study.

SETTING

Department of Obstetrics and Gynecology, Hospital das Forças Armadas, Lisbon, Portugal.

PATIENTS

Two hundred ninety-eight patients undergoing operative office hysteroscopy.

INTERVENTIONS

Pain intensity was assessed by patients using a numeric rating scale (0-10) 10 minutes after hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

Statistical analysis assessed the association between pain score and clinical, obstetric, and gynecologic history. Associations with procedure-related factors were also assessed. Lesion location did not influence the perception of pain in the current sample. Hysteroscopic anesthesia allowed for a significant reduction in pain scores, regardless of lesion location. Multivariate analysis revealed that only the type of operative procedure and operating time significantly influenced pain scores.

CONCLUSION

Hysteroscopic anesthesia allows for a well-tolerated procedure, regardless of lesion location during office hysteroscopy. Lesion location should not be regarded as a technical limitation.

Hysteroscopy as an investigation tool in recurrent implantation failure in vitro fertilization

OBJECTIVES

To evaluate the use of hysteroscopy in the assessment of uterine pathologies in infertile women with repeated implantation failure (RIF) after in vitro fertilization (IVF) and determine whether removal of such pathologies increased pregnancy rates in women with RIF.

METHODS

This prospective study was conducted at King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia, between January 2010 and December 2015. The inclusion criteria were women who underwent IVF treatment cycles and ended in more than 2 RIF, and women who underwent hysterosalpingography (HSG). Hysteroscopies were performed, findings were recorded, and the clinical pregnancy rates were compared and assessed in patients with and without uterine cavity abnormality. All hysteroscopic procedures were performed by a single consultant.

RESULTS

Hysteroscopies were performed on 266 women who  had at least 2 RIF. The average duration of infertility was 7.2±3.1 years. In 162 patients (60.9%), a hysteroscopy did not find any abnormality of the uterine cavity. In 104 patients (39.1%) there were one or more abnormal hysteroscopic findings. Hysterosalpingography was able to detect only 54 abnormalities (51.9%). The pregnancy rate was significantly higher in patients who were treated by a hysteroscopy for a detected uterine abnormality (39.4%).

CONCLUSION

A hysteroscopy was able to detect intrauterine pathologies which were missed by other investigative modalities. We believe patients with a history of RIF should undergo hysteroscopic examination before any further cycles are considered.

Pain relief for outpatient hysteroscopy

BACKGROUND

Hysteroscopy is increasingly performed in an outpatient setting. Pain is the primary reason for abandonment of procedure or incomplete assessment. There is no consensus upon routine use of analgesia during hysteroscopy.

OBJECTIVES

To assess the effectiveness and safety of pharmacological interventions for pain relief in women undergoing outpatient hysteroscopy, compared with placebo, no treatment or other pharmacological therapies.

SEARCH METHODS

In September 2016 we searched the Cochrane Gynaecology and Fertility (CGF) Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers (ClinicalTrials.gov and WHO ICTRP), together with reference checking and contact with study authors and experts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing use of pharmacological interventions with other pharmacological interventions and pharmacological interventions versus placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcome was mean pain score.

MAIN RESULTS

We included 32 RCTS (3304 participants), of which only 19 reported data suitable for analysis. Most studies were at unclear or high risk of bias in most of the domains assessed. The evidence was low or very low quality, mainly due to risk of bias and imprecision. Baseline pain scores were relatively low in all groups. Analgesic versus placebo or no treatment Local anaesthetics Local anaesthetics reduced mean pain scores during the procedure [(SMD) -0.29, 95% CI -0.39 to -0.19, 10 RCTs, 1496 women, I2 = 80%, low-quality evidence)] and within 30 minutes (SMD 0.50, 95% CI -0.67 to -0.33, 5 RCTs, 545 women, I2 = 43%, low-quality evidence). This translates to a difference of up to 7 mm on a 0-10 cm visual analogue scale (VAS) during the procedure and up to 13 mm within 30 minutes, which is unlikely to be clinically meaningful. There was no clear evidence of a difference between the groups in mean pain scores after > 30 minutes (SMD -0.11, 95% CI -0.30 to 0.07, 4 RCTs, 450 women, I2 = 0%, low-quality evidence), or in rates of vasovagal reactions (OR 0.70, 95% CI 0.43 to 1.13, 8 RCTs, 1309 women, I2 = 66%, very low-quality evidence). There was insufficient evidence to determine whether there was a difference in rates of non-pelvic pain (OR 1.76, 95% CI 0.53 to 5.80, 1 RCT, 99 women, very low-quality evidence). Nonsteroidal anti-inflammatory drugs (NSAIDs) There was insufficient evidence to determine whether there was a difference between the groups in mean pain scores during the procedure (SMD -0.18, 95% CI -0.35 to 0.00, 3 RCTs, 521 women, I2 = 81%, low-quality evidence). Pain scores were lower in the NSAIDs group within 30 minutes (SMD -0.25, 95% CI -0.46 to -0.04, 2 RCTs, 340 women, I2=29%, low-quality evidence) and at over 30 minutes (SMD -0.27, 95% CI -0.49 to -0.05, 2 RCTs, 321 women, I2 = 78%, low-quality evidence). This equates to maximum differences of under 7.5 mm on a 0-10 cm scale, which are unlikely to be clinically significant. One RCT (181 women) reported adverse events: there was insufficient evidence to determine whether there was a difference between the groups in vasovagal reactions (OR 0.76, 95% CI 0.20 to 2.94, very low-quality evidence). For other reported adverse events (non pelvic pain and allergic reactions) evidence was lacking. Opioids One RCT utilised sublingual buprenorphine and one utilised oral tramadol. Data on pain scores during the procedure were unsuitable for pooling due to inconsistency. Tramadol was associated with a benefit of up to 22 mm on a 0-10 cm scale (SMD -0.76, 95% CI -1.10 to -0.42, 1 RCT, 140 women). However, the effect estimate for this outcome for sublingual opioids did not support a benefit from the intervention (SMD 0.08, 95% CI -0.22 to 0.39, 164 women). Compared with placebo, the pain score within 30 minutes of the procedure was reduced in the tramadol group, with a difference of up to 17mm on a 0-10cm scale (SMD -0.57, 95% CI -0.91 to -0.23 , 1 RCT, 140 women, low-quality evidence. There was no clear evidence of a difference between the tramadol and placebo groups at over 30 minutes (SMD -0.17, 95% CI -0.51 to 0.16, 1 RCT, 140 women, low-quality evidence). Nausea and vomiting occurred in 39% of the buprenorphine group, and in none of the placebo group (OR 107.55, 95% CI 6.44 to 1796.46) Analgesic versus any other analgesic Some comparisons did not report pain scores at all time frames of interest, and none reported data on adverse events. One RCT (84 women) compared local intracervical anaesthesia versus combined intracervical and paracervical anaesthesia. Pain scores were higher in the group with local intracervical anaesthesia during the procedure (SMD 4.27, 95% CI 3.49 to 5.06, very low-quality evidence), within 30 minutes (SMD 1.55, 95% CI 1.06 to 2.05, very low-quality evidence) and at more than 30 minutes (SMD 3.47, 95% CI 2.78 to 4.15, very low-quality evidence). This translates to a possible benefit in the combined group of up to 12 mm on a 0-10 cm scale during the procedure. Benefits at longer follow-up were smaller. One RCT compared antispasmodic + NSAID versus local paracervical anaesthesia. Pain scores were lower in the NSAID group than in the local anaesthesia group (during procedure: SMD -1.40, 95% CI -1.90 to -0.91; >30 minutes after procedure: SMD -0.87, 95% CI -1.33 to -0.41; 80 women, very low-quality evidence). This suggests a possible benefit of during the procedure of up to 23 mm on a 0-10 VAS scale and up to 11 mm >30 minutes after the procedure. Other comparisons included local intracervical anaesthesia versus combined intracervical, paracervical and topical anaesthesia, and opioid versus NSAIDs. Findings were inconclusive.

AUTHORS' CONCLUSIONS

There was no consistent good-quality evidence of a clinically meaningful difference in safety or effectiveness between different types of pain relief compared with each other or with placebo or no treatment in women undergoing outpatient hysteroscopy.