Six thousand office diagnostic-operative hysteroscopies.

OBJECTIVE: To compare CO(2) and normal saline as distention media in office diagnostic hysteroscopy. METHODS: The outcome of more than 6000 office hysteroscopies was analyzed. We used carbon dioxide or saline as distension medium. Minor hysteroscopic techniques were performed when indicated. RESULTS: The major indication was abnormal uterine bleeding (45%). Satisfactory hysteroscopy was achieved in 92. 4% with CO(2) and in 98.3% with saline (P<0.05). Local anesthesia was used in 54 patients (1.5%) with CO(2) and in three patients (0. 1%) with saline (P<0.001). Four hundred and two women (16.3%) underwent hysteroscopic procedures under saline hysteroscopy. Endometrial polyps were removed in 281 patients, 75 IUDs were removed, 14 fibroids were extracted, uterine septa were excised in 11 cases and mild and moderate adhesions were transected in 21 patients. CONCLUSION: Saline office diagnostic hysteroscopy offers at least all the advantages of the CO(2) hysteroscopy, and gives the possibility to easily 'find and treat in situ' many of the lesions observed.     

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.     

Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies

AIMS: To determine whether performing transvaginal sonography (TVS) and saline infusion sonography (SIS) before hysteroscopy could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities. METHODS: Two hundred and twenty three women with suspected uterine cavity abnormalities were prospectively evaluated by TVS, SIS and hysteroscopy, and had histological evaluation of the endometrium with hysteroscopic biopsy or dilatation and curettage (D&C). One hundred and sixty five patients (74%) were premenopausal and 58 patients (26%) were postmenopausal. RESULTS: The positive predictive value (PPV) for endometrial polyps was 69% for TVS, 78% for SIS and 81% for hysteroscopy in premenopausal patients. In the postmenopausal group, TVS and SIS could detect only 24% of endometrial polyps, whereas 70% were diagnosed by hysteroscopy. The PPV for submucous fibroids was 47% for TVS, 81% for SIS and 77% for hysteroscopy in the premenopausal group. CONCLUSIONS: In premenopausal patients, SIS and hysteroscopy are equally accurate in the diagnosis of endometrial polyps and submucous fibroids. Hysteroscopy is the most accurate test for polypoid lesions in the postmenopausal group. Performing TVS, SIS and D&C could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities by 71.5% in premenopausal patients. However, this rate decreases to 40% in the postmenopausal group.     

Hysteroscopic findings in women with abnormal uterine bleeding according to the materials from the department of obstetrics and gynecology,medical university--Plovdiv

The results of a four-year period are analyzed. For this time 479 diagnostic panoramic hysteroscopies were performed. By 152 patients (31.7%) the main complaint was abnormal uterine bleeding. All hysteroscopies were followed by histological examination. The specimens have been taken by target biopsy and curretage. The age of the patients ranged from 40 to 75 years. Pointed is a frequency of this pathology and its distribution by age. The authors show the priority of the diagnostic panoramic hysteroscopy in consideration with the other methods of investigation--D & C and sonography, in fact-exactly diagnosis and avoiding unnecessary curretage.     

Technology assessment of saline contrast hysterosonography

OBJECTIVE: The purpose of our study was to evaluate to which extent saline contrast hysterosonography (SCHS) is able to replace diagnostic hysteroscopy in uterine cavity evaluation in women suspected of intrauterine abnormalities. STUDY DESIGN: In this prospective observational study we performed SCHS instead of diagnostic hysteroscopy. Diagnostic hysteroscopy was performed in case of failed or inconclusive SCHS. Univariate and multivariate analyses were used to assess subgroups for their risk of failure and inconclusiveness. RESULTS: Two hundred fourteen women were included consecutively. SCHS was conclusive in 180 cases (84.1%), failed in 12 (5.6%), and inconclusive in 22 (10.3%). Uterine size above 600 cm(3) was the best predictor of failure and/or inconclusiveness (positive predictive value 0.42). CONCLUSION: SCHS was able to replace 84% of the outpatient diagnostic hysteroscopies in uterine cavity evaluation in women suspected of intrauterine abnormalities. Our study showed that diagnostic hysteroscopy can be restricted to inconclusive or failed SCHS.     

The role of diagnostic hysteroscopy in infertile women

BACKGROUND: Anomalies of the uterus are considered one of the reasons for infertility in women. For this reason we believe diagnostic hysteroscopy is fundamental in screening for infertility. The aim of this study was to verify the incidence of uterine anomalies in sterile couples and evaluate the efficacy of diagnostic hysteroscopy in subjects with possible alterations in this organ. METHODS: From July through December 2000, 296 hysteroscopies were carried out at the Centro di Sterilità e di Fecondazione Assistita of Perugia University. Of these 223 entered the study because of infertility in couples. The exam was always done between the 7th and 11th day of the cycle using a Hamou 5 mm hysteroscope, without anaesthesia. The uterus was dilated by introducing physiological solution at 50 mmHg pressure. The criteria adopted for hysteroscopic findings were based on: a) cervical canal; b) uterine cavity; c) endometrium, and visualization of the ostium tubae. RESULTS: Of the 223 women who underwent hysteroscopy screening for infertility 17 (7.62%) had uterine anomalies. Of these 1 was in the cervical canal, 4 had anomalies in both the uterus and cervix, and the remaining 12 had only uterine cavity anomalies. The presence of neoformations was the most commonly found alteration. CONCLUSIONS: From the results of this study we conclude that diagnostic is a very important method for investigating the reasons for infertility in a couple. From our casuistry the incidence of uterine anomaly is 7.62%. We therefore suggest hysteroscopy be included among the 1st and 2nd level exams for female infertility.     

Intraoperative complications of 697 consecutive operative hysteroscopies

BACKGROUND: Complications due to hysteroscopy are relatively rare events. They occur more frequently with operative hysteroscopy than with diagnostic hysteroscopy. Exact complications rates are difficult to determine owing to the natural tendency to report successes but not complications. Recognition of these situations will lead to prevention; in fact, all the most serious complications of operative hysteroscopy can be avoided when proper precautions are taken and close communication is maintained among gynecologic surgeon, the anesthesiologist and nursing staff. The more clinically significant complications are: uterine perforation, haemorrhage and electrolyte imbalance. METHODS: Between January 1993 and December 1998, 697 women underwent operative hysteroscopy in our Department. Operative hysteroscopy was performed with continuous flow, high frequency resectoscope. Under general anesthesia the cervix was dilated to 10 mm and the uterine cavity was distended with 1.5% glycine solution or mannitol under 80 to 120 mmHg pressure. Resection with electrocoagulation was completed. The patients were submitted to the following procedures: 354 endometrial polypectomies (50.7%), 160 myomectomies (23%), 114 endometrial ablations (16.4%) and 69 hysteroscopic metroplasties (9.9%). RESULTS: In our series complications occurred in 95 out of 697 patients (13.6%). The most important complications were: 12 (1.7%) uterine perforations, 48 (6.9%) intraoperative haemorrhages and 35 (5%) excessive hypotonic fluid absorptions. Four out of 12 perforations occurred during the dilation of the cervical channel. Since the distention of the uterine cavity could not be achieved, the procedures were stopped. No signs of vaginal or intraperitoneal haemorrhage were observed; 8 out of 12 perforations were due to the tip of the electrical source. The operative hysteroscopies were immediately stopped and the consequences were: 6 diagnostic laparoscopies, 1 laparotic hysterectomy (hemorrhage) and 1 laparotomy for thermal bowel injury. In 48 patients intraoperative bleeding could not be controlled with electrocautery. In these cases in the operating room a Foley catheter was inserted into the uterine cavity and the bulb inflated with 10 to 30 mL of liquid to tamponade the bleeding. The catheters were removed 12 to 24 hours later. No patients required blood transfusion. Excessive intravasation of electrolyte-free fluid occurred in 35 patients. Hyponatremia and hypokalemia (hypo-osmolarity result) were never serious. Headaches, nausea and vomiting were the most frequent symptoms of our patients. No cardiac arrhythmia, cerebral edema, brain herniation occurred. In our series, hemorrhage was the most common complication; intravasation and uterine perforation were at the second and the third place. Complications rates decreased progressively du to a better major training and experience of the surgeons. Also the curves of each complication show a significant decrease. Myomectomy in our hands has been the most dangerous procedure. However, serious sequelae were rare mainly for two reasons: we prefer stop the intervention rather than continue when a deficit of 1.000 mL is reached. Consequently, it is very important to discuss the possibility of incomplete resection of the endouterine lesion with the patient preoperatively; a protocol for fluid management in the operating room must be used for all the procedures (also the easiest) by all the surgeons and the nurses. CONCLUSIONS: Our relatively high prevalence of intraoperative complications and distribution of the different types do not differ from the findings of published reports. In personal experience operative hysteroscopy is a safe surgical procedure for the treatment of endouterine abnormalities.     

Reliability,feasibility, and safety of minihysteroscopy with a vaginoscopic approach: experience with 6,000 cases

OBJECTIVE: To assess the reliability, feasibility, and safety of lens-based minihysteroscopy. DESIGN: Retrospective comparative study. SETTING: Academic research environment. PATIENT(S): Women with different indications for hysteroscopy. INTERVENTION(S): Six thousand seventeen outpatient diagnostic hysteroscopies with a minihysteroscope (2.7-mm outer diameter [OD] telescope with 3.5-mm OD single-flow diagnostic sheath) and 4,204 with traditional hysteroscope (4-mm OD telescope with 5-mm OD single-flow diagnostic sheath). All hysteroscopies were performed using a vaginoscopic approach and saline to distend the uterus. MAIN OUTCOME MEASURE(S): Rate of successful introduction of the hysteroscope, rate of satisfactory examinations, pain intensity experienced using an arbitrary pain scale (0 = no pain; 1 = low pain; 2 = moderate pain; 3 = severe pain), and number of side effects and complications. RESULT(S): In the minihysteroscopy, group rates of successful introduction and satisfactory examinations were significantly higher than in the traditional hysteroscope group (99.52% vs.72.53% and 98.53% vs. 92.33%, respectively), while pain and vagal reactions were significantly lower (0.10 +/- 0.34 vs.1.09 +/- 0.53 and 2.25% vs.17.12%, respectively). CONCLUSION(S): Hysteroscopy with lens-based minihysteroscopes was easier, less painful, more reliable, and safer than with 5-mm hysteroscopes. Minihysteroscopy with a vaginoscopic approach is a very well tolerated, effective, and safe outpatient procedure.     

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.     

Systematic hysteroscopy prior to in vitro fertilization

OBJECTIVE: To evaluate the benefits of a diagnostic hysteroscopy prior to in vitro fertilization. PATIENTS AND METHODS: We retrospectively studied 145 patients who underwent ICSI during a period of 6 months. Office hysteroscopy was systematically performed before the first stimulation cycle. If pathological findings were revealed, appropriate medical or surgical treatment was given. RESULTS: Pathological patterns were observed in 45% of hysteroscopies. Endometritis, polyps and myomas and mucosal diseases were the most frequently observed. The patients aged over 38 years didn't show higher rate of pathology (29% vs 27% for the younger patients). The treatment of pathologies gave the same pregnancy rate than the normal cavities. Patients with endometritis were treated with antibiotics and 40% of them became pregnant in the following cycle. DISCUSSION AND CONCLUSION: Systematic hysteroscopy prior to IVF-ICSI showed to be an effective investigation that could improve the pregnancy rate.     

Accuracy of office hysteroscopy in the diagnosis of endometrial hyperplasia

In the last decade the advantages of office hysteroscopy performed without cervical dilatation and/or anaesthesia were fully demonstrated. Many authors consider office hysteroscopy the gold standard diagnostic method in the diagnosis of intrauterine pathology, with high accuracy and compliance. The best sensitivity and specificity are reached in the diagnosis of focal lesions as submucous myomas and polyps but controversy still persists regarding hysteroscopic accuracy in the definition of endometrial hyperplasia. The aim of this prospective study was to evaluate the efficacy of outpatient hysteroscopy in the diagnosis of endometrial hyperplasia and to compare hysteroscopic findings with histology. From April 2000 to May 2002, 145 diagnostic office hysteroscopies were performed at the Euganea Medica clinic. Sensitivity in the detection of endometrial hyperplasia was 89.36%, specificity 91.96%, positive predictive value (PPV) 82.36% while negative predictive value (NPV) reached 95.37%. Uniformity of histology associated with outpatient mini-invasivity and high compliance favour office hysteroscopy and represent important elements in its diffusion as a first level diagnostic method even in the diagnosis of hyperplasia.     

Blood carbon dioxide tension changes during hysteroscopy.

During hysteroscopy the uterus may be distended with carbon dioxide (CO2), nitrous oxide (N2O), or Hyskon (a high molecular weight dextran). An initial study in 27 patients (group 1) using arterialized venous blood samples demonstrated rises in carbon dioxide tension (PCO2) when N2O was insufflated by using a laparoscopy insufflating device--a constant-pressure, variable-volume gas source. Cardiovascular collapse occurred in one patient in this group, most probably as a result of macropulmonary emboli of N2O. The rise in PCO2 is accounted for by an increase in physiologic dead space. In another 24 patients (group 2) the gaseous media were introduced by using a constant-volume, variable-pressure gas source; this resulted in minimal changes in arterial PCO2. The choice of whether a gaseous or liquid distending medium is used for hysteroscopy is governed by the state of the endometrium. If a gaseous medium is indicated, then CO2 is preferable to N2O and should be introduced with a constant-volume, variable-pressure gas source.     

The Efficacy of Hysteroscopy: A Comparison of Women Presenting With Infertility Versus Other Gynaecological Symptoms

Summary: The aim of this study was to compare the relative efficacy of hysteroscopy as a management tool in the routine initial assessment of women presenting for investigation of infertility with women presenting for investigation of other general gynaecological symptoms for which it is routinely performed. The results of 400 consecutive completed hysteroscopies performed during the primary investigation of infertility are compared with 400 consecutive completed hysteroscopies undertaken in the investigation of women with other gynaecological symptoms. Abnormalities were detected in 12.3% of the 800 hysteroscopies. Significantly less of the infertility group demonstrated abnormality (8.8%) compared to the general gynaecological group (15.8%) (p = 0.0034). There was no difference in the detection rate between primary and secondary infertility. In patients undergoing the procedure for infertility, the results of the hysteroscopy led to an alteration in management in 5.8% of the entire group and in 65.7% of those in whom an abnormality was detected. In patients undergoing the procedure for general gynaecological symptoms, the results of the hysteroscopy led to an alteration in management in 14.5% of the total group and in 97.2% of those in whom an abnormality was detected (p < 0.0001). Structural abnormality correlated with the presence of histological abnormality in 97.2% of cases. In infertile women, the use of hysteroscopy is supported as part of a comprehensive assessment of female reproductive anatomy.     

Postoperative infection and surgical hysteroscopy

OBJECTIVE: To evaluate the risk of infection after surgical hysteroscopy. DESIGN: Prospective observational study. SETTING: University hospital. PATIENT(S): One thousand nine hundred fifty-two patients requiring operative hysteroscopy during a 10-year period from January 1990 to January 2000. INTERVENTION(S): Two thousand one hundred sixteen operative hysteroscopies were performed: 782 fibroma resections, 422 polyp resections, 623 endometrectomies, 90 uterine septa sections, and 199 lyses of synechiae. MAIN OUTCOME MEASURE(S): Postoperative infectious complications. RESULT(S): Thirty (1.42%) infections occurred. There were 18 (0.85%) cases of endometritis and 12 urinary tract infections. No other severe infectious complications were reported. The risk for early-onset endometritis was higher after lysis of synechiae compared with endometrectomy, fibroma, or polyp resections. However, the risk for early-onset endometritis was similar for endometrectomy, septa, fibroma, or polyp resections. CONCLUSION(S): Infectious risk following surgical hysteroscopy is low. No major infectious complications occurred. Risk for early-onset endometritis was higher after lysis of synechiae compared with other procedures.     

Découvertes hystéroscopiques chez les femmes de 40 ans et moins avec saignement utérin anormal

Objective: describe hysteroscopic findings among women of 40 years old or less with abnormal uterine bleeding.Methods: this is a retrospective cohort study, using hospital and clinic files for the period of January 1988 to April 1997, where 191 patients 40 years old or younger had a diagnostic hysteroscopy for abnormal uterine bleeding. The rate of successful hysteroscopies, the type of anaesthesia, and hysteroscopic complications were listed. Type and frequency of intrauterine pathology, such as endometrial polyps, submucous myomas, hyperplasia and atrophy, were analyzed. Particular attention was devoted to the incidence of pathology which were not identified by endometrial biopsy (polyps and submucous myomas. Prior treatment before hysteroscopy was also assessed.Results: hysteroscopy was successfully completed in 95.8 percent of cases and the majority of the procedures 67.5% were done under local anaesthesia (paracervical block). No perforation or other major complication has been listed. Intrauterine pathology was diagnosed in 24 percent of patients and, among them, 9.8 percent had an endometrial polyp and 6.6 percent had a submucous myoma. About half of patients 45.9% had no treatment prior to hysteroscopy. Among those with previous treatments, 41 percent failed to respond to oral contraceptive therapy: in those patients, 13.3 percent had an endometrial polyp and 8.0 percent had a submucous myoma.Conclusion: hysteroscopy is a useful diagnostic approach for the investigation of patients 40 years old or less with abnormal uterine bleeding. In 24 percent of these patients, hysteroscopy enables the detection of intrauterine lesions. Most of which could not be detected by endometrial biopsy. According to this retrospective study, it seems preferable to recommend a diagnostic hysteroscopy rather than an endometrial biopsy for the investigation of abnormal uterine bleeding among women 40 years old or younger.     

Pathologic findings in hysteroscopy before in vitro fertilization-embryo transfer (IVF-ET).

BACKGROUND: The aim of this study was to evaluate hysteroscopy routinely performed prior to in vitro fertilization-embryo transfer (IVF-ET). METHODS: We analyzed in a prospective study 300 patients who underwent hysteroscopy before the first IVF-ET cycle. We analyzed then in a retrospective manner 300 patients who did not perform hysteroscopy. RESULTS: One-hundred-and-eighty (60%) hysteroscopies were normal but 120 (40%) revealed an unsuspected intrauterine abnormality. We did not find statistically significant differences between patients with normal or abnormal hysteroscopy in any characteristic. We found a statistically significant difference in pregnancy rate between women who performed hysteroscopy before IVF-ET cycle and in women who did not perform it. CONCLUSIONS: Hysteroscopy, as a routine examination, should be performed before the first IVF-ET cycle in all patients.     

Results of diagnostic hysteroscopy in a 7-year period in the gynecological clinic of "UMBAL-Pleven"

The aim of the authors is to show the data for the reception diagnosis, age, histological results and the conduct after the performed diagnostic hysteroscopies in Gynecological clinic of UMBAL-Pleven. For the fulfillment of this aim was made a prospective study for 7 years' period: from 01/01/1997 to 31/01/2003. The objects of observation were 74 women of age from 16 to 65 years, with performed hysteroscopies for gynecologic complaints. There were performed 74 diagnostic hysteroscopies for the studied period. The hysteroscopic findings were 20 cases with endometrial polyposis, 14--submucosal myoamatic nodes, deforming the uterine cavity, 4--cervical polyp, 19--increased endometrium, 9--Asherman syndrome, 1--bicomous uterus, 1--a suspected section for endometrial carcinoma and 6 cases without pathologic findings. There were performed 59 trial abrasions and the removed materials were sent for histological examination The performed comparative analysis between the hysteroscopic presentation and histological findings showed a coincidence of the diagnosis. It was made the conclusion, that the hysteroscopy is an easy, accessible and inexpensive diagnostic method, which must take its place as one of the basic contemporary diagnostic methods in gynecology.     

Two-year follow-up of patients with endometrial carcinoma after preoperative fluid hysteroscopy

Gücer F, Tamussino K, Reich O, Moser F, Arikan G, Winter R. Two-year follow-up of patients with endometrial carcinoma after pre-operative fluid hysteroscopy. Int J Gynecol Cancer 1998; 8 :476–480.
The aim of the present study was to analyze whether pretherapeutic hysteroscopy increases the recurrence rate in patients with endometrial cancer confined to the uterus. Between January 1993 and December 1995 a total of 33 patients with endometrial carcinoma underwent surgical staging following diagnostic fluid hysteroscopy and curettage at our department. Twenty-seven patients who had disease confined to the uterus without involvement of the uterine serosa formed the study group. Fifty-five patients with endometrial carcinoma confined to the uterus who had undergone surgery after diagnostic curettage without hysteroscopy during the same period were identified as controls. The median follow-up in the hysteroscopy group and the controls was 29 months (range 26–46) and 30 months (range 10–48), respectively. In the hysteroscopy group, no patient died of disease but one patient (3.7%) developed a local recurrence 37 months after primary treatment. In the control group, one patient (1.8%) had a local and para-aortic recurrence 20 months after primary treatment. Preceding diagnostic fluid hysteroscopy does not seem to increase the risk of early recurrence in patients with endometrial carcinoma histologically confined to the uterus.