A new device for "no touch" biopsy at "no touch" hysteroscopy: the H Pipelle

A new device for endometrial biopsy at "no touch" hysteroscopy has been developed based on the Pipelle. The modification (H Pipelle) facilitates endometrial sampling after hysteroscopy without the need to insert additional instruments into the vagina.     

"Hysteroscopy and female sterility: analysis of the results from 213 patients"

Hysterosalpinogography, laparoscopy and hysteroscopy are three complementary examinations in the morphological study of the utero-tubal factor of female sterility. The Authors describe their experience with Hamou's microhysteroscopy in the sterility diagnosis field: they confirm the advantages and new prospects offered by Hamou's microhysteroscopy, encountering uterine pathology in 34 percent of the studied patients and propose that all patients suffering from sterility and infertility problems should be subjected to hysteroscopy.     

Colouterine fistula complicating diverticulitis diagnosed at hysteroscopy: case report

Since Noecker first reported a colouterine fistula secondary to diverticulitis in 1929, about 20 cases have been reported in the literature. Methods for diagnosis have yet to be established. Herein we report the first case of a colouterine fistula at the level of the isthmus diagnosed at hysteroscopy. Diagnostic hysteroscopy enabled rapid diagnosis of the colouterine fistula. Diagnostic hysteroscopy is the first-choice diagnostic tool for investigation of any abnormal vaginal discharge such as blood or stool because it enables direct vision and biopsy of the lesions of the lower genital tract quickly and at low cost.     

Hysteroscopic myomectomy using bipolar energy: a gold standard?

In recent years, hysteroscopic resection has become the treatment of choice for submucous fibroids. Technological advances enabled the use of bipolar resectoscopes, in the same way as new bipolar instruments used in laparoscopy or open surgery. Bipolar systems would be expected to eliminate the risks of hyponatremia and electrical burns. In evaluation studies, bipolar energy used in operative hysteroscopy is as effective in comparison with the unipolar system. However, no clinical study has yet shown increased reliability of bipolar resection to consider their use as a gold standard. Outpatient operative hysteroscopy is now developing rapidly with the introduction of bipolar energy and small-diameter endoscopes. Although the financial impact is unknown, It allows time saving with maximal safety, avoiding cervical dilatation and anesthetic procedures.     

The Nurse's Role in Office Hysteroscopy

In recent years, hysteroscopy has been developed to provide physicians with direct visibility of the uterine cavity. Using carbon dioxide gas as a distending medium, office hysteroscopy has few side effects for women. It is also more cost effective than outpatient surgery. The nurse's role is pivotal in simplifying office hysteroscopy through empathetic preparation and support of women, careful planning, procurement of necessary items, and finally, conscientious care of the instruments.     

The role of office hysteroscopy in in vitro fertilization.

Twenty-eight patients participated prospectively in a study to evaluate the impact of hysteroscopically detected uterine and cervical anomalies on the success rate of ET in an IVF-ET program. All participants had a normal intrauterine cavity by standard HSG. All the patients had a diagnostic office hysteroscopy under paracervical block before commencing COH. Because our IVF program does not include hysteroscopy as a requirement before undergoing IVF and because the significance of mild intrauterine abnormalities is not yet known, the hysteroscopic findings were not relayed to the personnel involved in the IVF-ET procedure. Sixteen patients (group I) had a normal hysteroscopic evaluation. Twelve patients (group II) had abnormal hysteroscopic findings including small uterine septa, small submucous fibroids, uterine hypoplasia and cervical ridges. Although no difference in patients or cycle characteristics was present, there was a significant difference in the clinical PR between patients in groups I and II. In conclusion, in an IVF-ET program patients with normal hysterography but abnormal hysteroscopic findings had a significantly lower clinical PR, demonstrating the importance of performing hysteroscopy before IVF-ET.     

Hysteroscopy and ultrasonography in the diagnosis of endometrial cancer

The main aim of investigating women with abnormal uterine bleeding is to exclude serious intrauterine pathology, particularly endometrial cancer. Endometrial assessment has traditionally been achieved by obtaining tissue for histological analysis utilising blind in-patient dilatation of the cervix and curettage of the endometrium under general anaesthesia. This procedure is now generally accepted as outmoded practice associated with unnecessary morbidity and cost and has been largely replaced by minimally invasive out-patient or 'ambulatory' diagnostic modalities. These modalities include transvaginal ultrasonography, out-patient hysteroscopy and miniature endometrial biopsy. The most controversial debate has centred on how best to image the uterine cavity with advocates of hysteroscopy and ultrasonography holding apparently implacable views. However, the concept of hysteroscopy and ultrasonography as competing tests may be misplaced, and perhaps they should be viewed as complementary diagnostic tools. To help us answer such questions requires an appraisal of the available evidence. In this way, a more rational approach to investigating women for endometrial cancer is possible based on the clinical and economic performance of hysteroscopy and ultrasonography. This review assesses the evidence and suggests approaches available to gynaecologists for the diagnostic work-up of women suspected to have endometrial cancer utilising hysteroscopy and ultrasonography.     

Indications of diagnostic hysteroscopy, a brief review of the literature

Plenty of authors propose outpatient hysteroscopy as the gold standard diagnostic method for the evaluation of endometrial pathology. This statement has been strengthened in the recent years due to the wide use of smaller diameter hysteroscopic devices, which have made the dilation of the cervix and the use of anesthesia unnecessary. The main purpose of this paper is to summarize the indications of diagnostic hysteroscopy. In this review, we used the most recent publications in MEDLINE and Cochrane Library in order to specify the indications of diagnostic hysteroscopy and the experience that have been obtained till today in the management of certain pathological uterine conditions. The key words we used were diagnostic hysteroscopy, abnormal uterine bleeding, infertility, endometrial cancer. Hysteroscopy provides an accurate method of evaluation and direct visualization of the endometrial cavity and moreover directed biopsy and sampling of suspected lesions. Last years with the continuous development in the hysteroscopy devices, plenty of women benefit surgical hysteroscopy techniques for uterine abnormalities. Hysteroscopy is useful for the diagnosis in patients with abnormal uterine bleeding, with endometrial cancer and in infertile women. Hysteroscopy has the unique advantage of combining a thorough procedure with great diagnostic accuracy. The only disadvantage is that hysteroscopy requires specific teaching and training and has a long learning curve.     

Hysteroscopy training in the UK: the trainees’ perspective

The advanced hysteroscopy special skills module has been developed by the Royal College of Obstetricians and Gynaecologists (RCOG) in association with the British Society of Gynaecologic Endoscopists (BSGE). It is mainly aimed at senior specialist registrars in obstetrics and gynaecology in their final two years of training, but it can also be undertaken by non-training posts in the same field. By completion of the module, ideally within a year, trainees are expected to have reached independent competence in performing both diagnostic, as well as operative hysteroscopy. A survey was done on trainees attending the mandatory course at the RCOG (intermediate/advanced hysteroscopic surgery course in 2006), which is part of the requirement for obtaining the Advanced hysteroscopy special skills module. Feedback was obtained from 44 trainees who were either already registered for the special skills module in advanced hysteroscopy or were planning on registering. Overall, 50% of candidates found the one-year target difficult to achieve. The majority attended at least one hysteroscopy outpatient clinic per week (85%) and/or one hysteroscopy theatre list per week (87%). This suggested the adequate attendance of hysteroscopy sessions; however, the problem was with operative hysteroscopy, which comprised 0–20% of training for the majority of trainees (59%). The conclusion was that the one-year target for obtaining the special skills module was difficult to achieve, with the most evident cause being the inability to acquire the expected operative hysteroscopy standard within the intended time.     

宫颈机能不全的孕前诊断方法及评价

宫颈机能不全是妊娠期因子宫局部因素导致围产儿发病率与病死率的主要原因,其发生率约0.1%～1.0%。孕前病史如流产与早产病史、孕前子宫畸形病史、宫颈手术病史等是诊断宫颈机能不全的关键;其次为影像学检查,最常用的方法为阴道超声,X光下子宫输卵管造影、磁共振成像已较少采用;宫颈内口扩条探查法及Foley导管水囊牵拉试验在诊断时有一定主观性,且有宫腔感染风险,在临床上也较少使用;腹腔镜及宫腔镜检查受技术及设备限制,一般医院较少开展。此外,宫颈机能不全可能与基因变化有关,但尚未得到证实。综合病史及辅助检查,在孕前早发现、早诊断,并予以正确的孕前指导和治疗,可在一定程度上避免再次妊娠的丢失与早产,改善妊娠结局。     

A comparison of outpatient hysteroscopy with saline infusion hysterosonography

Objectives To establish the accuracy of saline infusion hysterosonography in diagnosing uterine pathology when compared with outpatient hysteroscopy.
Design Prospective, parallel, blinded comparative study.
Setting Outpatient hysteroscopy clinic in a large university teaching hospital.
Population All women referred for outpatient hysteroscopy in a 15-month period.
Interventions Women underwent saline infusion hysterosonography followed by flexible hysteroscopy. The ultrasonographer was blinded to the hysteroscopy result and the gynaecologist was blinded to the saline infusion hysterosonography result.
Main outcome measures The relative success rates and pain scores for each procedure. The validity of saline infusion hysterosonography as a diagnostic test.
Results One hundred and seventeen women entered the study; 70 women were premenopausal and 47 postmenopausal. In 27 women, one or both procedures could not be performed. Saline infusion hysterosonography failed in 20 women, on one occasion hysteroscopy failed and both investigations failed in six women. Ninety cases remained for direct comparison, with 78 cases of agreement on the uterine findings in both investigations. Twelve cases disagreed; in one case, an adhesion was seen, two cases with polyps and five with fibroids seen on ultrasound but not seen on hysteroscopy. There were four cases where polyps were identified on hysteroscopy but not on saline infusion hysterosonography. The median pain scores were 1.6 for saline infusion hysterosonography and 3.2 for hysteroscopy.
Conclusions Both saline infusion hysterosonography and hysteroscopy are well tolerated by women. Saline infusion hysterosonography has a high failure rate but has a lower pain score than hysteroscopy.     

Office hysteroscopy.

Office hysteroscopy has developed into an easy, safe, quick, and effective method of intrauterine evaluation that provides immediate results, offers the capacity of direct targeted biopsies of suspicious focal lesions, and offers the direct treatment of some intrauterine conditions. It has been facilitated by the availability of small-caliber endoscopes. Because of its simplicity and ease, the procedure is applicable as a screening method for patients with abnormal uterine bleeding or questionable hysterograms and for patients with suspected intrauterine pathology. Office hysteroscopy can be undertaken in a short period of time with minimal morbidity and inconvenience to the patient. It is important, nonetheless, to select the patients appropriately and time the examination strictly to the early follicular phase, once menstruation has ceased. When suction aspiration plastic cannulas are used for endometrial sampling, the combined procedure, hysteroscopy-suction sampling, offers an excellent method in the evaluation of patients with abnormal uterine bleeding. Transvaginal sonography with or without fluid enhancement complements the uterine evaluation, rather than replacing hysteroscopy, by outlining intramural uterine lesions such as myomas, adenomyosis, and other adnexal pathology not susceptible to hysteroscopic evaluation. Although some patients may not require analgesia or anesthesia for office hysteroscopy, the majority will benefit from a paracervical block or topical anesthesia, particularly if a suction endometrial aspiration will follow hysteroscopy or if any hysteroscopic intervention is performed, including a targeted biopsy. The success office hysteroscopy depends on the appropriate selection of the patient, the absence of contraindications, adequate instrumentation, and meticulous technique.     

Diagnose uteriner Blutungen

Abnormal uterine bleeding is a gynecological problem frequently seen in women from adolescence to the postmenopausal period. Nearly 70% of patients' visits to the gynecologist in the peri- and postmenopausal period are due to abnormal uterine bleeding. Diagnostic procedures in the gynecologist's office differ greatly and depend on the reproductive age of the individual patient. It is very important to have precisely specified the type of bleeding disorder and in premenopausal patients to differentiate between ovulatory and anovulatory cycles after excluding pregnancy. Taking a family history may provide information about familial coagulation disorders. Laboratory studies should include a pregnancy test and possibly a diagnosis of any hormonal disorders. For decades the standard diagnostic procedure to distinguish between normal and pathological endometrium was dilatation and curretage. Various studies, however, have cast doubt on the reliability of this method since curettage only reached less than half of the uterine cavity in 60% of cases and after hysterectomy endometrial carcinoma had not been diagnosed in 15% of cases by dilatation and curretage. The preferred diagnostic method in abnormal uterine bleeding is 5-mm hysteroscopy. With this method the whole uterine cavity can be visualized. In combination with a targeted biopsy, almost 100% rates of sensitivity and specificity can be achieved. In particular, intrauterine polyps and submucosal myomas, which are often missed with dilatation and curretage, can be diagnosed with certainty by hysteroscopy. Diagnostic hysteroscopy involves virtually no complications and can be performed on an outpatient basis in 94% of cases. Thanks to further improvements in the optics and reductions in the shaft diameter, the “mini-hysteroscope,” a flexible 2.4-mm optic, was developed, making dilatation of the cervical canal and any form of anesthetic unnecessary in 98% of cases. Transvaginal sonography has proven to be a good means of screening to distinguish between normal and pathological endometrium. For such indications, it shows a 96% sensitivity and 86% specificity in premenopausal patients with respect to hysteroscopic findings. Intrauterine changes cannot be differentiated with certainty on sonography and so any if there are any unusual findings, hysteroscopy should always be performed. Although some authors are in favor of sonohysterography, it has not yet gained clinical acceptance everywhere in Germany. By instilling saline solution in the uterine cavity a similarly high sensitivity in differentiating between myomas and polyps can be reached as with hysteroscopy; however, specificity is lower.     

Current practical application of office endoscopy.

Outpatient hysteroscopy has shown good correlation of findings compared with inpatient hysteroscopy, but one limitation is pain and discomfort in some women, and vasovagal reaction. Various forms of local anaesthesia have been evaluated in the past year, with controversial results, and a narrow 3.5 mm sheath hysteroscope has been introduced. Transvaginal hydrolaparoscopy as an outpatient procedure has been further investigated.     

Is routine hysteroscopy during LLETZ a valuable additional procedure?

We aimed to critically review our experience with the value and risks of a diagnostic hysteroscopy performed in addition to LLETZ. We retrospectively included 442 womentients undergoing LLETZ and additional routine diagnostic hysteroscopy. Women for whom concomitant diagnostic hysteroscopy was somehow indicated were excluded. We focused on complications and intrauterine abnormalities detected by hysteroscopy that had not been seen on preoperative vaginal ultrasound. In 28/442 (6.3%), hysteroscopy and/or histological examination of the specimen removed by curettage revealed an abnormal intrauterine finding (benign endometrial polyps, n=20; benign cervical polyps, n=2; small leiomyomas inside the uterine cavity, n=1; septate/arcuate/unicornuate, n=5). A total of 38 surgical complications (8.6%) occurred. The two adverse events related to diagnostic hysteroscopy were uterine perforations (0.5%). In conclusion, only a few benign findings of questionable clinical relevance were discovered. Thus, we do not consider an additional routine diagnostic hysteroscopy during LLETZ beneficial for the patient.     

Future growth and development of hysteroscopy

In less than two decades, hysteroscopy has evolved into a practical technique for the evaluation of the uterine cavity, with well-established indications such as evaluation of abnormal uterine bleeding and abnormal hysterograms as well as the treatment of intrauterine adhesions or the septate uterus, the removal of misplaced or embedded intrauterine devices, and the removal of submucous leiomyomas. As the use of hysteroscopy increases and more practitioners utilize it, new instrumentation and techniques are beginning to evolve, simplifying and facilitating not only a diagnostic examination, but also the more difficult and complex surgical interventions. Flexible endoscopes are being tested for possible use in the uterine cavity, and operative hysteroscopes with practical inflow and outflow accessory channels have been introduced. The accessory operative instrumentation has also been expanded and refined, and portable units for office examinations have been developed. The trend in the development of instrumentation is toward simplicity, effectiveness, and refinement in lenses with wider fields of view and accessory channels without compromising the total outer diameter of the endoscopes. As clinical applications expand as a result of increased use and proficiency in hysteroscopy, new applications undoubtedly will follow, such as closer study of the endometrium with and without additional magnification. This latter may permit a better understanding of the receptivity of the endometrium to the embryo, which may help in predicting successful nidations. Portable laser units with the capability to use the CO2 fiber undoubtedly will increase laser use through hysteroscopy, and in the near future, photodynamic therapy may become the best approach to the selective treatment of intrauterine lesions. The uterotubal junction will remain an attractive area for endoscopists to approach the fallopian tubes transcervically and eventually to accomplish tubal closure safely and effectively with the possibility of future reversibility. The hysteroscope will play an important role in new reproductive technologies, particularly those related to the gamete intrafallopian transfer via the uterine side and perhaps also for direct embryo transfers under visual control. The future of hysteroscopy thus is promising. The present diagnostic and therapeutic applications will not only become a standard of treatment but will expand as gynecologists will gain proficiency and confidence in this endoscopic method.     

Tubal sterilization via laparoscopy and hysteroscopy.

The combination of a growing need for improved contraceptive technology, plus the new advances in endoscopic equipment, have resulted in widespread use of laparoscopic sterilization throughout the world. Recent developments have succeeded in making hysteroscopy a reliable technique and it too has been quickly evaluated for a new, simpler female sterilization method. This work is still in progress and no reliable clinical method is yet available. However, the use of a chemical, such as methyl cyanoacrylate, delivered by hysteroscope, or possibily by a blind method, does seem to be most promising as a new clinical technique shortly.     

"Chromohysteroscopy" for evaluation of endometrium in recurrent miscarriage

PURPOSE: "Chromoendoscopy" results in 34 recurrent miscarriage (MR) patients in whom conventional hysteroscopy did not show any apparent endometrial pathology. METHOD: 5 ml of 1% methylene blue dye was introduced through the hysteroscopic inlet. RESULTS: The study group was classified according to the staining characteristics. Group I included 19 patients in whom focal dark staining was observed. Group II included 15 patients in whom diffuse light blue staining was observed. There was no significant difference between the two groups in age, smoking, status, BMI, number of miscarriages and in mean gestational age of the miscarriages. Time to hysteroscopy after the last miscarriage was shorter in Group I (63.9 vs 95.3 days). Then, the study group was classified according to the histopathology result. Group I included ten cases of endometritis while Group II included 24 cases with a normal histopathology. The mean number of miscarriages was higher in Group I (3.4 vs 2.5). CONCLUSION: Chromohysteroscopy improves the efficacy of hysteroscopy in RM cases and is warranted after three miscarriages in two cycles time.     

Office hysteroscopy: a valuable but under-utilized technique

PURPOSE OF REVIEW: The purpose of this review is to remind gynecologists of the indications for office hysteroscopy as well as to provide an update on equipment, techniques, and reimbursements. RECENT FINDINGS: Office hysteroscopy is a technique that has been available for over three decades. Whereas nearly 100% of urologists utilize office cystoscopy to evaluate bladder pathology, it is estimated that less than 20% of gynecologists utilize office hysteroscopy to evaluate intrauterine pathology. Although no one knows for sure, I speculate that the reasons for its under-utilization include a perceived lack of patients who would benefit from the procedure, expensive capital equipment with poor reimbursement, and a lack of expertise in performing the procedure. SUMMARY: As a result of not routinely using office hysteroscopy, many women who could greatly benefit from the use of the office hysteroscope are being denied a technique that is likely to keep them from more invasive and less useful procedures, such as diagnostic hysteroscopy and dilatation and curettage performed in the operating room under general anesthesia. This paper addresses these misconceptions in an effort to encourage more gynecologists to employ this technology.     

Diagnostic hysteroscopy and risk of peritoneal dissemination of tumor cells

Questions have been raised about the safety of diagnostic hysteroscopy preceding surgical treatment of endometrial carcinoma. Several studies showed that the risk of a positive cytology among patients presenting endometrial adenocarcinoma was increased after diagnostic hysteroscopy, suggesting a peritoneal dissemination of tumor cells due to the exploration. We studied this hypothesis on the basis of a systematic review of the scientific data. Five studies fulfilling inclusion criteria have been selected and have been introduced into a fixed model of meta-analysis. On a total of 756 studied patients, 79 presented a positive peritoneal cytology. The diagnostic hysteroscopy did not increase significantly the risk of abdominal dissemination of tumor cells, the peritoneal cytology being positive among 38 patients in the group having undergone this intervention vs 41 patients in the control group (OR = 1,64; 95% CI: 0,96-2,80). In conclusion, no formal evidence is currently available concerning the role of diagnostic hysteroscopy on the frequency of peritoneal dissemination of tumor cells, or on the vital prognosis of the patients presenting with endometrial carcinoma. From the data available, there is not any reason to avoid diagnostic hysteroscopy in the initial workup of endometrial cancer.