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

Background

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

Objective

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

Material and Methods

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

Main outcome measures

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

Results

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

Conclusion

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

Hysteroscopic metroplasty

STUDY OBJECTIVE

To evaluate 10 years' experience with hysteroscopic treatment of septate uterus in Italy.

DESIGN

Multicenter retrospective study conducted from January 1988 to March 1997 (Canadian Task Force classification II-2).

SETTING

Twelve Italian centers for minimally invasive therapy.

PATIENTS

Women (total 973) with hysteroscopically diagnosed septate uterus.

INTERVENTIONS

Hysteroscopic metroplasty performed with scissors, resectoscope, or neodymium:yttrium-aluminum-garnet laser.

MEASUREMENTS AND MAIN RESULTS

Data on indications for hysteroscopic metroplasty, details of patient management from pretreatment to follow-up, and pregnancy course and delivery were collected by questionnaire. Main indications were two or more abortions and primary infertility. Most procedures were performed with the resectoscope, followed by scissors and laser. Few minor complications occurred. Pregnancy rates were good.

CONCLUSION

Hysteroscopy is safe and effective treatment of septate uterus in terms of both pregnancy rate and outcome.

[The role of hysteroscopy in the diagnosis and follow-up of endometrial hyperplasia]

BACKGROUND

Preneoplastic lesions of endometrium such as endometrial hyperplasia (simple and complex with or without cytological atypias) represent an important cause of abnormal uterine bleeding. Among diagnostic techniques, hysteroscopy presents several advantages: it is an out-patient procedure, minimally invasive, repeatable, of rapid execution and with low cost. The hysteroscopic pattern of endometrial hyperplasia appears with an over-development of the endometrial mucosa with increased glandular openings, increased vascularization, cystic dilatations, polypoid aspects.

METHODS

Since October 1984 to January 1995 at the Gynecologic Endoscopic Service of Obstetrics and Gynecology Department of the University of Bologna, 13,438 hysteroscopies were performed: 291 (2.16%) in patients submitted to hysteroscopy for previous diagnosis of endometrial hyperplasia. The first diagnosis of endometrial hyperplasia was made in 125 (42.3%) patients through hysteroscopic biopsy, while for 166 patients (57.04%) the first diagnosis was made by endometrial curettage of VABRA.

RESULTS

The results showed that the endometrial hyperplasia is typical in perimenopausal age and this finding is more frequently symptomatic. The histological diagnosis after hysteroscopy was: simple hyperplasia in 106 patients (84.8%), complex in 12 patients (9.6%) and atypical in 6 patients (4.8%). One case of simplex hyperplasia was associated with endometrial cancer (0.8%). The comparison between histological diagnosis and hysteroscopic diagnosis showed that agreement is reached in 113 cases (90.4%). However, it is to note that diagnostic agreement of complex hyperplasia cases was about 100%, but in 22 cases the hysteroscopic diagnosis was simplex hyperplasia rather than complex or atypical. The errors of hysteroscopy were observed in 10 cases (8%).

CONCLUSIONS

The hysteroscopic diagnosis should not replace histological diagnosis, mostly in hysteroscopies performed after progestagen therapy, because the changes induced by drugs make more difficult the interpretation of hysteroscopy. However, hysteroscopy is complementary to histological analysis since permits a global evaluation of endometrial mucosa, directs biopsy on dishomogeneous areas and represents the only means to make diagnosis when biopsy is not practicable.

[Outpatient diagnostic hysteroscopy: 14,000 cases]

Hysteroscopy is a technique which plays a fundamental diagnostic role in gynecological practice. The possibility of obtaining a direct intracavitary view and performing specific biopsies give it a greater level of diagnostic accuracy than intrauterine curettage. The authors' personal experience of 13,923 case enables the correct method of performing this procedure to be codified in order to avoid the inherent risks and complications. The main indication is abnormal uterine bleeding which is the most frequently observed pathology in gynecological practice. In cases of metrorrhagia in women of child-bearing age benign organic pathology accounts for 45% of patients and malignant pathology 0.3%. Post-menopausal patients reveal an increase in the incidence of organic pathology in general and neoplastic pathologies in particular (8.1%). Complications linked to this type of technique are extremely rare and in overall terms affect 1% of cases. The analysis of results shows that hysteroscopy today represents an extremely reliable and repeatable outpatient procedure. However, in spite of these advantages, including savings in health costs, it is not widely used at a capillary level given that if performed by persons who are not expert it may become traumatic and unreliable. The correct execution of hysteroscopy in fact calls for dexterity acquired over time which is not conditioned by the learning of previous techniques and requires an adequate period of training.

Transvaginal sonography vs. hysteroscopy in the preoperative staging of endometrial carcinoma

The aim of this study was to evaluate the diagnostic accuracy of transvaginal sonography vs. hysteroscopy in the preoperative staging of endometrial carcinoma, in order to establish the most appropriate surgical therapy. Transvaginal sonography and hysteroscopy were used preoperatively in 67 women with histologically proven endometrial carcinoma. Deep myometrial invasion (> 50%) was present at postoperative pathology in 26/67 (39%) women and spread to the cervix occurred in 11/67 (16%) women. Transvaginal sonographic examination was initially directed at assessing myometrial invasion, which was correctly predicted in 52/67 (78%) women. Transvaginal sonography demonstrated a sensitivity of 88% (23/26) and a specificity of 71% (29/41) for deep invasion, with a positive predictive value (PPV) of 66% (23/35) and a negative predictive value (NPV) of 91% (29/32). The accuracy of transvaginal sonography in detecting cervical involvement was 82% (55/67), and that of hysteroscopy was 72% (48/67): transvaginal sonography was slightly less sensitive (54% vs. 64%), but more specific (87% vs. 73%) than hysteroscopy. When cervical invasion was present, the PPVs of transvaginal sonography and hysteroscopy were 46% (6/13) and 32% (7/22), respectively, while the NPV was 91% for both techniques (49/54; 41/45). Our data show that the accuracy of transvaginal sonography was comparable with that of hysteroscopy in detecting cervical involvement. Therefore, in the majority of cases, when both techniques showed that disease was limited, the appropriately limited type of surgery would be performed. Conversely, detection of a myometrial invasion of > 50% or an extension to the cervix would lead to an unnecessarily extensive operation if this was the sole criterion used for making the decision.

A case of unsuspected endometrial stromal sarcoma removed by operative hysteroscopy

A 26-year-old woman underwent operative hysteroscopy to remove a polypoid lesion, responsible for recurrent abnormal uterine bleeding. The polypoid mass was 4 cm long, smooth, with dilated vessels. It had a large base and originated from the fundum and posterior wall of the uterus. Pathological examination of the resected specimen showed low-grade stromal sarcoma. The patient subsequently underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. No tumor residual was found in the surgical specimen. As diagnosis of stromal sarcoma is too difficult to be made preoperatively, the complete resection of all intracavitary lesions and the pathology of all tissue specimens are suggested.

Hysteroscopic metroplasty

Between February 1990 and June 1993 40 patients underwent hysteroscopic metroplasty for septate uterus. Twenty-six patients had previous miscarriages (65%) and fourteen were infertile (35%). Hysteroscopic section of uterine septa was performed by means of Hamou resectoscope with sorbitol-mannitol solution as distending medium. Surgical outcome was excellent without intraoperative and postoperative morbidity. After 40-60 days the uterine cavity was completely epithelialized without intrauterine adhesions in all the cases. One patient had incomplete septum section that required a second procedure. Postoperative reproductive outcome was evaluated in 26 patients: the cumulative pregnancy and birth rate was 73% and 86%, respectively. Five patients delivered by cesarean section (39%). In the infertile group the pregnancy and birth rate was much lower (44% and 75%, respectively) than in previous miscarriage group (88% and 91%, respectively). Infertile patients do not seem to be cured by hysteroscopic metroplasty; however, in these cases the endoscopic operation should be performed, because it may prevent subsequent miscarriage. Hysteroscopic metroplasty by means of Hamou resectoscope is a very successful, quick, simple and safe procedure that may replace abdominal metroplasty.

A method for evaluating human tubal motility in vivo: a new approach for infertility investigation

The motility of the Fallopian tube plays an important role in the gametes and embryo transport. Disorders of the tubal motor function may be involved in a great number of patients with unexplained infertility. The aim of this study was to develop a method to measure the tubal motility by means of an hysteroscopic approach in humans. The following motor parameters were evaluated: 1) the basal pressure of each 1 cm tract of the tube; 2) amplitude and frequency of the tubal contractions; 3) the uterine intraluminal pressure eight patients in the follicular phase (FP group) and 8 in the luteal phase (LP group) of the menstrual cycle, were studied. The duration of the motility recording session was 12 +/- 3 minutes (range 7-19 minutes). No significant differences were shown between the two groups of patients, and no differences were found between the recordings obtained from the right and the left tubes.