Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

Diagnosis of endometrial cancer and its precursors

Whereas cervical carcinoma is reliably detectable by the noninvasive methods of cytological/cervical smear and HPV typing even in the early stages, endometrial carcinoma thus far eludes effective check-up. Neither ultrasound nor invasive procedures such as Pipelle de Cornier, abrasio fracta or hysteroscopy, succeeded in making the majority of endometrial carcinomas detectable at an early stage in systematic screenings. Several factors contribute to this fact: first, only a fraction of these carcinomas develops through early stages of atypical hyperplasia, whereas the majority develops de novo. As the most suitable screening method in general, ultrasound fails in pre- and perimenopausal women, who account for 30% of new endometrial carcinoma cases. Moreover, patient compliance with preventive examinations is especially low in the high risk population of senior women. And, finally, there are issues regarding the clinical consequences of improved diagnosis, since endometrial carcinomas may become clinically significant in only 1 of every 4-6 patients, whereas the majority of these malignomas remains clinically inapparent. Hence, atypical uterine bleeding will continue to be the main symptom prompting hysteroscopic and histological clarification (H&H) and ensuing detection of endometrial carcinomas and their early stages.

Hysteroscopic resection of submucous myomas

Within just a few years, operative hysteroscopy has largely replaced laparotomy in the treatment of submucous myomas. Due to the rapid expansion of hysteroscopic surgery techniques, guidelines must be defined to standardize the procedure and at the same time provide the basis for highly individualized treatment of each patient. The choice of an appropriate therapeutic approach in this context is an issue of logistics, rather than surgery. Factors contributing to the individualized decision regarding the therapeutic approach include indications, individual anatomical conditions encountered, necessity of medical pretreatment, available equipment and adequate premises at the surgical center, and intraoperative procedure of choice. Taking into consideration all these issues, the present article aims at presenting to the surgeon not only a summary of the state-of-the-art techniques, but also a guideline for sophisticated strategy planning for and performance of the hysteroscopic technique of myoma resection.

Tamoxifen-induced hyperplasia of the endometrium

Greatly thickened endometria are often observed in vaginal sonography in patients taking tamoxifen. The incidence of type I carcinoma of the endometrium is also raised under tamoxifen. Both effects are ascribed to the known partial estrogenic effect of tamoxifen. However, if sonographically hyperplastic endometria are abraded, mostly only atrophic material is obtained. To clarify this contradiction, 89 patients treated with tamoxifen were investigated by means of vaginal sonography at intervals of 6 months. In 33 of them (37%), an endometrial thickness > 8 mm was found. In order to investigate the endometrial thickness throughout, a hysteroscopic loop resection (polyps n = 18, diffuse hyperplasia n = 15) and afterwards histological work-up of the endometrium in serial sections were carried out in all these patients. Hyperplasia of the endometrial stroma without cellular atypia was found in all cases. However, the glandular epithelium was always atrophic. This explains the contradiction between sonographically thick endometrium (stromal hyperplasia) and the scanty abrasion material (atrophy of the glandular epithelium). The 'hyperplasia' found sonographically is not necessarily estrogen-dependent hyperplasia of the glandular epithelium leading to a carcinoma. This raised the question as to the etiological reasons for the increased incidence of carcinomas. We discuss the hypothesis that tamoxifen may also promote the conversion of pre-existent subclinical lesions into manifest carcinomas.

Uterine and fetal findings at hysteroscopic evaluation of spontaneous abortions before D&C

STUDY OBJECTIVE

To evaluate the diagnostic benefit of fluid hysteroscopy before dilatation and curettage (D&C) in women with missed abortion, with respect to frequency of congenital and acquired uterine anomalies and geographic relationship of uterine anomalies to nidation site.

DESIGN

Prospective case study (Canadian Task Force classification II-2).

SETTING

Obstetric-gynecologic clinic of an academic teaching hospital.

PATIENTS

One hundred five women with one or more recurrent missed abortions.

INTERVENTION

Hysteroscopy before D&C. Inspection of the fetus was attempted in 62 patients. Control hysteroscopy of the nonpregnant uterus was performed in 20 patients.

MEASUREMENTS AND MAIN RESULTS

The uterine cavity was visualized in 87 patients (83%). These women had an obstetric history significant for 143 spontaneous abortions in 208 pregnancies. Except for three small, finger-shaped polyps in the tubal ostia, no uterine anomalies were detected. In 20 women control hysteroscopy of the nonpregnant uterus confirmed initial findings. The fetus was successfully visualized in 30 cases (48%). We observed one case of umbilical cord torsion at 12 weeks' gestation.

CONCLUSION

Absence of uterine anomalies in patients with single as well as recurrent spontaneous abortions was unexpected since it contradicts the existing literature. However, all previous data were gathered from hysteroscopies of nonpregnant uteri. Larger comparative studies are required.

The oestrogen receptor (ER) in normal and abnormal uterine tissue

Glandular epithelium and stroma of the endometrium show typical behavioural patterns in the expression of oestrogen receptors (ERs) due to both endogenous and exogenous hormonal influence. Thus, the ER is increasingly expelled under the influence of oestrogen during the first half of the cycle. Under the influence of progesterone, the ER disappears during the luteal phase and is not even detectable after day 21. During menopause, the atrophic endometrium typically shows very little, if any, ER expression. In cases of oestrogen-induced hyperplasias, the receptor can again be demonstrated. The ER only disappears when nuclear irregularities occur in cases of adenomatous hyperplasia. In cases of invasive carcinoma, a heterogenous picture is seen which closely correlates with the degree of differentiation.

[Room air as the etiology of gas embolism in diagnostic CO2 hysteroscopy]

During a diagnostic CO2-hysteroscopy in general anesthesia, a manifest gas embolism with a resulting drop of the endexpiratory CO2 partial pressure occurred upon insertion of the instrument. By ending the procedure and through appropriate anesthesiological measures, the occurrence was brought under control and the embolism had no clinical consequences. The incidence encouraged us to reconsider the CO2-hysteroscopy examination technique. As a result, we describe an up to now neglected mechanism which may lead to air embolism in gas hysteroscopy: Similar to hysteroscopy with fluid distension, the whole system has to be purged from air by insufflating CO2 prior to examination. If this step is neglected, up to 40 cm3 of room air may be insufflated into the patient, considering a connective tubing of 200 cm length and 0.5 cm lumen. The scientific organisations as well as the endoscopic training centers and the manufacturers of hysteroflators are challenged to deal with this newly described potential cause of complications.

The etiology, frequency, and prevention of gas embolism during CO(2) hysteroscopy

STUDY OBJECTIVES

To assess the frequency of clinically apparent and undetected cardiopulmonary emboli during diagnostic CO(2) hysteroscopy, to determine the causes of these events, and to define a risk profile.

DESIGN

Retrospective and prospective case study (Canadian Task Force classification II-2).

SETTING

Obstetric-gynecologic clinic of an academic teaching hospital.

PATIENTS

Five thousand one hundred ninety-three women.

INTERVENTION

Diagnostic CO(2) hysteroscopy performed between September 1990 and December 1998.

MEASUREMENTS AND MAIN RESULTS

From September 1990 to December 1996, 1 (0.03%) severe but nonfatal embolism occurred in 3932 diagnostic CO(2) hysteroscopies. Undetected emboli were present in 20 patients (0.51%). Starting in January 1997 the gas supply tube (volume 40 ml) was deaerated before the procedures, and no emboli occurred in the next 1261 examinations up to December 1998. The decrease in frequency was statistically significant (p = 0.009). No pathologic flow sounds were found in any of 50 hysteroscopies monitored by Doppler stethoscope.

CONCLUSION

A manifest gas embolism is rare in diagnostic CO(2) hysteroscopy. The 10% to 50% frequency of undetected gas emboli cited by other authors could not be confirmed. If the supply tube system that holds room air is purged with CO(2) before the procedure, the already low risk drops to zero or almost zero, confirming the theory that emboli that occur during CO(2) hysteroscopy are caused by room air.

Possibilities and limits of operative hysteroscopy: an update on transcervical resectoscopic uterine surgery

In infertility therapy operative hysteroscopy by means of high-frequency surgery has replaced laparotomy in many cases. Thus today the therapy of intrauterine synechias, septa and myoma is a major sector in hysteroscopic metroplasty. Uterine haemorrhage is another area of indications for transcervical high-frequency surgery. In menstrual disorders caused by polyps, submucous myoma or without any anatomic reason transcervical electrosurgery helps to avoid more and more hysterectomies. The increasing importance of this method becomes obvious in the 1991-AAGL-Survey according to which within three years the number of operative hysteroscopies has risen to 17,298, thus doubled within this period of time. The present article based on literature and personal experience gives an overview of technical equipment available, complications, operative technics and risks. Furthermore, the frequency of success and complications of transcervical resectoscopic surgery are also discussed.

[Tumor cell seeding caused by hysteroscopy?]

154 patients suffering from endometrial carcinoma who underwent CO2-hysteroscopy pretherapeutically, were examined as to whether hysteroscopy lead to tumour cell spread to the peritoneal cavity and worsened the prognosis of the patients. For that purpose, both fallopian tubes of 118 women were investigated thoroughly by histology for intratubarian spread of tumourous cells. Only in one of the 118 patients a single tumour cell complex was detected inside the ampullar part of a fallopian tube. Comparing the investigated patients with data from the literature in terms of five-year survival rates and frequency of relapses, our collective showed the same outcome as those from the literature. These results prove, that the prognosis of endometrial carcinoma is not worsened by CO2-hysteroscopy.

Use of an implantable catheter system for intraperitoneal chemotherapy in ovarian cancer

To check the efficiency of intraperitoneal chemotherapy of ovarian carcinomas, 15 patients were treated with instillations of mitoxantrone or cisplatinum. An implantable catheter system was used to access the abdominal cavity. Local therapy proved to be without any effect when large tumor masses were treated. Patients with small tumor residues after surgery did not benefit either, partly because of extraperitoneal progress of the disease. Patients without evidence of disease proved to be stable. Side effects of the therapy were usually mild compared with those of systemic chemotherapy. Access to the peritoneal cavity with the implantable catheter proved to be safe and reliable.

[Value of vaginal ultrasonography in noninvasive assessment of the endometrium of the postmenopausal uterus]

The endometrial carcinoma shows an increasing incidence and represents today the most frequent malignoma of the female pelvis. Until now all techniques of detection of this carcinoma or its precursors are invasive and thus are not suitable for screening investigations. Vaginosonography, as the first non-invasive diagnostic method, now supplies knowledge about the state of the endometrium. At the Gynaecological Department of the University of Homburg/Saar, West Germany, 221 patients had been preoperatively subjected to vaginosonography before they underwent surgery. Sonographical and histological findings corresponded in atrophic endometrium in 82%, in regular, perimenopausal endometrium in 91%, in endometrial polyps and hyperplasia of the endometrium in 56%, and in endometrial carcinoma in 79%. With regard to the detection of endometrial cancer, a specificity of 96%, a sensitivity of 93%, a positive predictive value of 79% and an accuracy of 96% were established. Thus, according to our experience, vaginosonography represents a valid, non-invasive diagnostical method as a suitable instrument for screening the endometrium.

[Slit drainage versus Redon drainage in a clinical comparison--initial experiences with a new kind of wound drainage system]

In a prospective, randomised study we compared the clinical properties of the established Redon drain with a new type of drain called "slit drain". Both types of drains were examined regarding the amount of drained fluid, the time elapsing until removal of the drain, the frequency of occlusion of the lumen as well as the patient's pain and the required force at extraction of the drain. The statistical analysis showed both drains to have equal abilities in draining of fluid if they were used under vacuum conditions. If used as nonsuction drains, the new device was able to drain more fluid than the established type of drain (p less than 0.05). Statistically relevant advantages of the slit drain were seen in a lower rate of obstruction of the lumen, a higher amount of drained fluid (as non-suction device) as well as an easier and less painful extraction.

[Marshall-Marchetti-Krantz operation with fibrin gluing. Results after 2 years]

Since broad experience concerning the stability of fibrin sealing is needed, it has become part of the routine program in orthopaedics and in traumatology. Because of these experiences, we decided to modify the standard Marshall-Marchetti-Krantz-Operation replacing all sutures on both sides of the urethra and the bladder neck by fibrin sealing. So far, 76 patients have been operated using to this new method. All patients had a urinary stress incontinence grade II-III, urodynamically verified and a pronounced urethro-cystocele. To judge the results of the operation the following check-ups were instituted: 1. Urodynamic control, 2. lateral cyst-urethrogram, 3. gynecological examination (anatomical control), 4. subjective, individual evaluation of the patient concerning the involuntary loss of urine. Our study shows that we achieved good surgical and functional results as can be demonstrated both clinically and by urodynamic check-up. The advantage of this method of operation using fibrin sealing is to be seen in the broad lifting up of the anterior vaginal wall without unphysiological fixation and at the same time avoiding all risks of sutures.