Vaginoscopic hysteroscopy in management for women with post-menopausal vaginal bleeding

ObjectivesThe feasibility of vaginoscopic hysteroscopy combined with office endometrial biopsy after ultrasonography for management of post-menopausal vaginal bleeding (PMB).Materials and methodsA prospective observational study of with PMB whom attending the Outpatient Clinic of Kang Ning Hospital during a four months period (1st Feb to 31st May 2018) was included. Vaginoscopic hysteroscopy was performed with endometrial biopsy after the initial clinical pelvic examination and transvaginal ultrasound examination.ResultsA total of 45 consecutive women with PMB was included. The hysteroscopy and endometrial biopsy were successful in 44 out of 45 (98%), a complete view in 82%, adequate tissue was in 91%, only one case was failed both procedures due to pain. The correlation between hysteroscopy and endometrial biopsy by was 100%. The mean operation time was 229 ± 68 s. The most common histological findings was atrophic endometrium 18 (42%). Five endometrial polyps and 2 submucosal leiomyomas were found. One rare case of endometrial carcinosarcoma (2%) was detected. Patients reported less pain for hysteroscopy than endometrial biopsy with rated VAS pain score was 3.5 ± 2.2, with 5 more score in 18%, and for endometrial biopsy 4.2 ± 2 and 33% respectively (p < 0.001). Six cases (13%) experienced vasovagal attacks immediately after the procedure. There is no other complication.ConclusionThe Vaginoscopic hysteroscopy combined endometrial biopsy is safe and feasible for assessment of endometrial pathology with postmenopausal bleeding.     

Vaginoscopic Resection for Vaginal Rhabdomyosarcoma during Early Infancy: A Case Report

Embryonal rhabdomyosarcoma, a malignant soft tissue neoplasm, is 1 of the most common pediatric tumors of the vagina. Although radical surgery has been replaced with radiation therapy, chemotherapy, and conservative surgery, the use of vaginoscopy is still uncommon. We present the case of an infant who underwent vaginoscopic resection because of botryoid sarcoma at 9 months of age.     

宫腹腔镜临床应用评价

近年来,随着腔镜技术的日臻成熟,宫腹腔镜联合手术已成为临床诊治多种妇科疾病的重要手段。宫腹腔镜联合手术具有快速、准确、创伤小等优点,现以较能显示宫腹腔镜联合手术特点的疾病(如不孕症、子宫畸形)及妊娠相关疾病等为切入点,总结其在各个疾病诊治中的应用,以期对临床工作有一定的指导作用。     

A Novel Robotic Endoscopic Device Used for Operative Hysteroscopy

To trial the use of a novel endoscopic robot that functions using concentric tube robots, enabling 2-handed surgery in small spaces, in a bioengineering laboratory. This was a feasibility study of the endoscopic robot for hysteroscopic applications, including removal of a simulated endometrial polyp. The endoscopic robot was successfully used to resect a simulated endometrial polyp from a porcine uterine tissue model in a fluid environment. The potential advantages of this platform to the surgeon may include improved exposure, finer dissection capability, and use of a 2-handed surgical technique. Further study regarding the safe, efficient, and cost-effective use of the endoscopic robot in gynecology is needed.     

Vaginoscopic resection for rhabdomyosarcoma of the vagina: a case report and review of the literature

Rhabdomyosarcoma is the most common soft-tissue sarcoma found in children. Genitourinary sites comprise 20% of the primary location of these tumors. A polypoid form of the embryonal type of rhabdomyosarcoma, sarcoma botyroides, is often found in girls under age 5. These tumors are usually localized to the anterior vaginal wall. Their superficial location and clinical symptoms lead to early diagnosis, and these tumors are therefore considered to be the easiest to treat and most likely to be cured. In the past 30 years we have seen a shift in treatment from radical surgery to conservative surgery with chemotherapy and radiation, with improved survival and preservation of normal anatomy and improved postoperative body imagery. Conservative excision in the past has been performed by sharp curettage of the anterior vaginal wall. We present a case of a 2-yr-old child with a RMS of the vagina for which we utilized vaginoscopy not only to determine the extent of the tumor but also for precise resection using a bipolar electrode with normal saline as the distension medium.     

Analgesia for Office Hysteroscopy: A Systematic Review and Meta-analysis

ObjectiveTo identify the most effective analgesia for women undergoing office hysteroscopy.Data SourcesWe searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library from inception until August 2019 for studies that investigated the effect of different analgesics on pain control in office hysteroscopy.Methods of Study SelectionWe included randomized controlled trials that investigated the effect of analgesics on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting compared with the control group.Tabulation, Integration, and ResultsThe literature search returned 561 records. Twenty-two studies were selected for a systematic review, of which 16 were suitable for meta-analysis. There was a statistically significant reduction in pain during office hysteroscopy associated with preprocedural administration of nonsteroidal anti-inflammatory drugs (NSAIDs) (standardized mean difference [SMD] –0.72; 95% confidence interval [CI] –1.27 to –0.16), opioids (SMD –0.50; 95% CI –0.97 to –0.03), and antispasmodics (SMD –1.48; 95% CI –1.82 to –1.13), as well as with the use of transcutaneous electrical nerve stimulation (TENS) (SMD –0.99; 95% CI –1.67 to –0.31), compared with the control group. Moreover, similar reduction in pain was observed after office hysteroscopy: NSAIDs (SMD –0.55; 95% CI –0.97 to –0.13), opioids (SMD –0.73; 95% CI –1.07 to –0.39), antispasmodics (SMD –1.02; 95% CI –1.34 to –0.69), and TENS (SMD –0.54; 95% CI –0.95 to –0.12). Significantly reduced pain scores with oral NSAID administration during (SMD –0.87; 95% CI –1.59 to –0.15) and after (SMD –0.56; 95% CI –1.02 to –0.10) office hysteroscopy were seen in contrast to other routes. Significantly more adverse effects were reported with the use of opioids (p <.001) and antispasmodics (p <.001) when compared with the control group, in contrast to NSAIDs (p = .97) and TENS (p = .63).ConclusionWomen without contraindications should be advised to take oral NSAIDs before undergoing office hysteroscopy to reduce pain during and after the procedure. TENS should be considered as an alternative analgesic in women with contraindications to NSAIDs.     

Simulation for Training and Assessment in Hysteroscopy: A Systematic Review

Hysteroscopy simulation complements conventional training on patients, yet evidence-based recommendations about its implementation and use are lacking. This systematic review analyzes and critically discusses hysteroscopy simulation literature published over the last 30 years. Systematic searches on PubMed, Embase, PsychINFO, ERIC, and the Cochrane Library produced 27 original articles published through 2017. Strategies based on different simulation models (e.g., animal organs, vegetables, synthetic uteri, virtual reality) were evaluated by users and appeared to facilitate learning. Observational studies have suggested a large impact on the knowledge and technical skills of novices for a wide range of hysteroscopic procedures, including for diagnosis, resection, and sterilization. Pretest/posttest studies show large improvements in performance time (6 studies; pooled effect size, 1.45; 95% confidence interval, 1.06–1.85) and overall performance scores (4 studies; pooled effect size, 3.19; 95% confidence interval, 1.45–4.94). Additionally, performance assessment on simulated models distinguishes novices from experts. Caution should be exercised because the available evidence largely originates from heterogeneous studies with weak designs, conducted in experimental settings with nonclinical participants (i.e., medical students). Moreover, neither clinical outcomes nor the clinical value of simulation-based assessment has been addressed. Hysteroscopy simulation may be supported ethically and pedagogically, but its role should be evaluated in pragmatic contexts, with robust interventional studies and broader competence-defining outcomes that include nontechnical skills.     

Efficacy of Antibiotic Prophylaxis for Hysteroscopy: A Meta-Analysis of Randomized Trials

ObjectiveTo assess the efficacy and side effects of antibiotic prophylaxis compared with placebo or no treatment in women undergoing hysteroscopy.Data SourcesA structured search was carried out in PubMed-Medline, Embase, and Cochrane Controlled Trials Register databases through December 31, 2018.Methods of Study SelectionThe search included a combination of the following terms: “hysteroscopy,” “endoscopic surgery,” “antibiotic prophylaxis.” The following outcomes were selected: postoperative fever, infection rate, pelvic inflammatory disease (PID) and abscess occurrence, postoperative antibiotic requirement, and side effects occurrence (lower abdominal pain, vomiting, diarrhea, anaphylactic reaction). A random-effects model was used at meta-analysis. Study quality and bias risk were assessed with the Cochrane tool.Tabulation, Integration, and ResultsFive randomized controlled trials comparing efficacy of antibiotic prophylaxis with placebo or no treatment were included in the meta-analysis. Overall, pooled incidence of events was very low in both groups (fever, 3.79% vs 1.8%; overall infection, .52% vs .58%; postoperative antibiotic therapy, 1.18% vs 1.32%; and lower abdominal pain, 12.46% vs 9.31%). Moreover, the incidence of serious infections requiring further actions (PID or abscess) appeared to be extremely low (.2% in pretreated women and none in control groups). No one trial individually or the pooled analysis showed a statistically significant benefit of antibiotics prophylaxis over placebo for the outcome considered.ConclusionThe use of antibiotics appears not to be beneficial to prevent infection after hysteroscopy; however, the lack of high-quality studies makes it difficult to draw firm conclusions. Considering the very low infection rate highlighted after hysteroscopic procedures, a difference will probably never be proven in a randomized trial. A larger population and program data to confirm these results are therefore warranted.     

Hysteroscopy for evaluation of tubal ostium pathology

A comparison between hysterosalpingography and hysteroscopy in the evaluation of tubal ostium pathology is presented by the authors. They stress in particular the role of hysteroscopy in this evaluation.     

Hysteroscopy in a program of in vitro fertilization

Two hundred twenty-four women underwent hysteroscopic evaluation without anesthesia after at least two failed attempts of in vitro fertilization and embryo transfer. One hundred fifty-three (68%) women were diagnosed as having mechanical infertility, and abnormal hysteroscopic findings were observed in 32 (21%). Forty-one women were diagnosed as having unexplained infer-tility (18%) and six (15%) had abnormal findings with hysteroscopy. Of the 30 couples who entered the in vitro fertilization regimen program because of male infertility, 4 (13%) had abnormal findings. The overall rate of abnormal findings was 19%; cervical canal and intrauterine abnormalities were found in 10 and 32 patients, respectively. Ten patients were treated during hysteroscopic evaluation procedure, and four patients subsequently underwent operative hysteroscopy under general anesthesia. We suggest that diagnostic hysteroscopy should be a routine procedure before in vitro fertilization and embryo transfer therapy.     

以宫腔镜手术为主的综合治疗在宫腔粘连性不孕中的应用

目的:探讨以宫腔镜手术为主的综合治疗在宫腔粘连性不孕中的应用价值。方法:回顾性分析67例宫腔粘连患者的治疗效果,均经宫腔镜下机械性粘连分离术及输卵管间质部插管通液术,术后宫腔放置宫内节育器及雌、孕激素周期治疗。结果:67例宫腔粘连中轻度粘连24例,中度粘连25例,重度粘连18例。46例1次手术成功重建宫腔,21例2次手术。术后88.1%宫腔形态正常,79.1%月经恢复正常,输卵管通畅率72.1%。术后妊娠率50.7%,活产率85.3%。无手术并发症。结论:宫腔镜对于不同程度宫腔粘连的宫腔重建微创、有效。术中注意保护子宫内膜;疏通阻塞的输卵管对提高妊娠率至关重要。     

宫腔镜在子宫恶性肿瘤诊治中的应用与思考

宫腔镜检查加直视下活检诊断子宫内膜癌较超声、诊断性刮宫等方法可靠,对萎缩性子宫内膜的诊断更具优越性。宫腔镜手术治疗子宫恶性肿瘤正在探索中。宫腔镜检查有促使瘤细胞腹腔内扩散的可能,是否影响患者预后尚无定论。     

Hysteroscopy with selective endometrial sampling compared with D&C for abnormal uterine bleeding: the value of a negative hysteroscopic view

Hysteroscopic evaluation of 187 patients with abnormal uterine bleeding is reviewed. One hundred fifty-one patients had recent tissue sampling by a blind method. The hysteroscope with selected endometrial sampling was more accurate in 9.1% and less accurate in only 0.5% of patients. The specificity of both techniques with selected biopsies was 100%, but the sensitivity of hysteroscopy was greater (98%) than that of D&C (65%). Endometritis was the only condition missed by hysteroscopic viewing and selected biopsy. Those lesions missed by blind tissue sampling were uterine fibroids and endometrial polyps. Among 91 patients whose hysteroscopic view was negative, an abnormality was identified by tissue sampling in only one patient with endometritis.     

A Novel Approach for Resection of a Vaginal Septum

BackgroundThe resection of a vaginal septum using the Harmonic Scalpel in a patient on anticoagulation is described.CaseA 21-year-old female with bicollis didelphys uterus and a 4-cm vaginal septum underwent resection of the vaginal septum using the ultrasonic scalpel. Hemostasis was noted both during and after the procedure. The patient was given thombophylaxis for 2 weeks perioperatively secondary to her medical history of anti-thrombin III deficiency and deep venous thrombosis.Summary and ConclusionThe use of the Harmonic Scalpel appears to be a safe and effective method for resection of vaginal septa. Patient healing time may vary and may take longer than with traditional techniques.     

The Biopsy Snake Grasper Sec. VITALE: A New Tool for Office Hysteroscopy

Hysteroscopic evaluation of the endometrium with biopsy can be performed using different graspers whose terminal ends have specific features. This technical note aims to describe an innovative hysteroscopic grasper, the biopsy snake grasper sec. VITALE (Centrel S.r.l., Ponte San Nicolò, Padua, Italy), which can be used to grasp and cut at the same time. The characteristic features of this grasper are as follows: a sleeve with an opening along the whole width, a flat pointed tip with serrated edges fixed to its end by a U-shaped joint, and 2 sharp-edged jaws that completely encompass the tip when they are clenched. The biopsy snake grasper sec. VITALE, therefore, aims to be a useful innovative tool. It is a robust, easy-to-use instrument compatible with all modern hysteroscopes equipped with a 1.67-mm (5 French) working channel.     

Office Hysteroscopy and Curettage — A Safe Diagnostic Procedure

In a series of 50 patients investigated by office hysteroscopy and curettage, satisfactory direct inspection of the cervical canal and uterine cavity was possible in all patients. In addition satisfactory endometrial specimens suitable for reliable histological evaluation were obtained in 98% of patients. No endometrium was obtained in 1 postmenopausal patient. Patients chosen for this form of investigation are those with an indication for diagnostic curettage who have no serious cardiovascular disease, are not bleeding or have light bleeding, and are willing to have an office procedure. Currently office curettage is done with a 5mm Karman catheter with an attached 10ml syringe for suction. Local analgesia is rarely used.