Hysteroscopic polypectomy: a comparison between 22 Fr and 26 Fr resectoscopes under paracervical block anesthesia, a randomized controlled study

Outpatient Hysteroscopy: (Green-top Guideline no. 59)

All gynaecology departments should provide a dedicated outpatient hysteroscopy service to aid care of women and people with abnormal uterine bleeding, reproductive problems, and insertion/retrieval of intrauterine devices. [Grade A] Written information should be provided to the woman prior to their appointment. This should include details about the procedure, the benefits and risks, advice regarding pre-operative analgesia, as well as alternative options for care and contact details for the hysteroscopy unit. [Good Practice Point] Women should be made aware of other settings and modes of anaesthesia for hysteroscopy (e.g. under general or regional anaesthesia or intravenous sedation). [GPP] The woman should be advised that if they find the procedure too painful or distressing at any point, they must alert the clinical team who will stop the procedure immediately. The clinical team should alert the hysteroscopist if the woman appears to be in too much pain or is experiencing a vasovagal episode and therefore unable to voice the concerns so that the procedure can be stopped. [GPP] Women should be advised to take standard doses of oral non-steroidal anti-inflammatory agents (NSAIDs) one hour before their scheduled appointment. Vaginoscopy should be the standard technique for outpatient hysteroscopy unless the use of a vaginal speculum is required (e.g. for administering local cervical anaesthesia or dilating the cervix). [Grade A] When performing operative hysteroscopy, the smallest diameter hysteroscope should be used, with consideration given to the use of hysteroscopes with expandable outer working channels because they are associated with less pain. [Grade B] Mechanical hysteroscopic tissue removal systems should be preferred over miniature bipolar electrodes to remove endometrial polyps. [Grade A] Local anaesthesia should not be routinely administered prior to outpatient hysteroscopy where a vaginoscopic approach is used. It should be considered where use of a vaginal speculum is planned e.g. for cervical dilatation if anticipated, due to either cervical stenosis and/or the utilisation of larger-diameter hysteroscopes (≥5mm outer diameter). [Grade A] Saline should be instilled at the lowest possible pressure to achieve a satisfactory view. [Grade A] Conscious sedation should not be routinely used in outpatient hysteroscopic procedures. [Grade B].

Anesthesia-free In-office Hysteroscopic Morcellation for Endometrial Polyps: A Prospective Study

Objectives

The objective of the study was to evaluate the feasibility and quality of anesthesia-free in-office hysteroscopic morcellation for the treatment of endometrial polyps.

Materials and Methods

A prospective, single-center, open-label, single-arm clinical trial was conducted to evaluate the efficacy of hysteroscopic morcellation for endometrial polyps or retained products of conception. All surgical procedures were performed using the TruClear™ 5C system in the office setting without anesthesia. The primary endpoint was the success rate of surgery, defined as the completion of the operation. The secondary endpoints were operating time, fluid deficit, adverse events, pain evaluated by Visual Analog Scale (VAS) scores, and recurrence rate.

Results

Ninety-five patients underwent hysteroscopic morcellation without anesthesia and received the treatment. The success rate of surgery was 100% (95/95), and the mean operating time was 7.3 min. Adverse events occurred in only 2.1% (2/95), with vasovagal reflex. The mean VAS scores during the procedure ranged from 2.4 to 3.1, and the recurrence rate after 6 months was 2.1% (1/47), with a pregnancy rate of 33% (11/33). When comparing nulliparous and parous patients, the success rate and the operating time were equivalent, and the mean VAS scores during the procedure were both within tolerable levels but significantly higher in nulliparous patients (3.3-4.5 vs. 1.6-1.9, P < 0.001).

Conclusion

This study demonstrated that anesthesia-free in-office hysteroscopic morcellation for endometrial polyps can be safely performed with feasible quality and only tolerable pain. This less-invasive procedure is expected to become more widespread in future.

Removal of uterine polyps: clinical management and surgical approach

Endometrial polyps have a reported prevalence from 7.8% up to 30% and are one of the most cost-consuming gynecological conditions for our specialty. There are strong practitioner beliefs that surgical removal of endometrial polyps is highly beneficial, particularly for those with abnormal uterine bleeding and infertility. Additionally, polypectomy is indicated to reduce the risk of malignancy. Transvaginal ultrasound is the first-line diagnostic option for detection of endometrial polyps, while sonohysterography has similar accuracy as hysteroscopy in the diagnostic confirmation. Blind dilatation and curettage is not recommended for polyp removal; rather, hysteroscopy in the operating room and office setting using small-diameter hysteroscopic equipment is the standard approach. This can be performed without anesthesia in most women. While hysteroscopy is an effective method for polypectomy with a low complication rate, it is unknown whether this is truly beneficial for reproductive-age women with infertility and prior assisted reproduction therapy. The risk of malignancy in women with postmenopausal bleeding justifies the necessity of polypectomy with histologic tissue examination. In asymptomatic women, the risk of malignancy is low, and there are no known benefits of polyp removal in the prevention of malignant transformation. Cost-effective studies remain to be done to provide us with the optimal approach to endometrial polyps including the management of asymptomatic and/or infertile women, ideal location including office-based or the operating room setting, complication prevention including intrauterine adhesions, and recurrence issues.

Pain and Operative Technologies used in Office Hysteroscopy: A Systematic Review of Randomized Controlled Trials

OBJECTIVE

To identify technologies associated with the least operative pain in women undergoing operative office hysteroscopic procedures.

DATA SOURCES

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched until January 2021 using a combination of keywords "hysteroscop*," "endometrial ablation," "outpatient," "ambulatory," "office," and associated Medical Subject Headings.

METHODS OF STUDY SELECTION

Randomized controlled trials evaluating the effect of hysteroscopic devices on pain experienced by women undergoing operative office hysteroscopy were included. Data were also collected regarding efficacy, procedural time, adverse events, and patient/clinician acceptability and/or satisfaction.

TABULATION, INTEGRATION, AND RESULTS

The search returned 5347 records. Ten studies provided data for review. Two trials compared endometrial ablation using bipolar radiofrequency with thermal balloon energy, with no significant difference in pain observed (p <.05). Seven trials evaluated technologies for endometrial polypectomy, of which, 4 compared energy modalities: miniature bipolar electrode resection against resectoscopy (N = 1), morcellation (N = 2), and diode laser resection (N = 1). Two studies compared hysteroscope diameter, and one study compared methods of polyp retrieval. A significant reduction in pain was found using morcellators rather than miniature bipolar electrosurgical devices (p <.001), 22Fr rather than 26Fr resectoscopes (p <.001), and 3.5-mm fiber-optic hysteroscopes with 7Fr forceps rather than 5-mm lens-based hysteroscopes with 5Fr forceps (p <.05). One study investigating septoplasty showed significant reduction in pain when cold mini-scissors, rather than a miniature bipolar electrode, were used (p = .013). Average procedural times ranged from 5 minutes 28 seconds to 22 minutes. The incidence of adverse events was low, and data regarding efficacy and acceptability/satisfaction were limited.

CONCLUSION

Pain is reduced when mechanical technologies such as morcellators and scissors are used compared with electrical devices for removing structural lesions in the office. For hysteroscopic and ablative procedures, smaller and quicker devices are less painful. Large-scale RCTs investigating patient pain and experience with modern operative devices in the office setting are urgently needed.

Four year evaluation of therapeutic hysteroscopy under procedural sedation in an outpatient clinic

OBJECTIVE

Due to the evolution of hysteroscopic instruments, therapeutic hysteroscopic procedures are increasingly performed in an outpatient, office-based setting. The most important limiting factor of performing these hysteroscopic treatments is patient discomfort. Procedural Sedation Analgesia (PSA) decreases patient discomfort and anxiety. The main goal of this study is to determine safety, feasibility and patient satisfaction of therapeutic hysteroscopy performed under procedural sedation in an outpatient clinic. Our second objective was to compare 9 mm scopes with smaller diameter scopes.

STUDY DESIGN

All consecutive patients suitable for procedural sedation and scheduled for a therapeutic hysteroscopy in the outpatient clinic were prospectively included from February 2014 to November 2018 in a teaching hospital in the Netherlands. A variety of therapeutic hysteroscopies procedures was performed including myomectomy, removal of retained products of conception and endometrial ablation. Therapeutic hysteroscopes with 3.8 mm, 5 mm and 9 mm diameter were used. In all selected women procedure time, admission time, pain scores, anaesthesiologic and procedural complications were assessed. All women received a questionnaire on patient satisfaction.

RESULTS

In total 455 patients underwent a therapeutic hysteroscopy. Median procedure time was 11 min (2-63 min) and median admission time was 130 min (30-480 min). Median pain score according to the visual analog scale (VAS) before, during and after procedure were respectively 0 (0-10), 0 (0-4) and 0 (0-9). Anaesthesiologic complication rate was 4.4 %, all minor. Procedural complications consisted of infection postoperatively (0.4 %), excessive blood loss during procedure (0.6 %) and perforation (0.4 %). Procedure was incomplete in 3.3 % of all procedures. Patient satisfaction was high, as 96 % of the women were satisfied. No differences were found in pain scores, VAS 0 versus 1 after the procedure, between 3.8 or 5 mm and 9 mm scopes.

CONCLUSION

It is safe and feasible to perform a therapeutic hysteroscopy under procedural sedation in an outpatient setting, with low pain scores and a high degree of patient satisfaction, also when large diameter instruments are used.

Innovations in hysteroscopic surgery: expanding the meaning of "in-office"

Surgical innovations in hysteroscopic surgery have radically changed the way of treating intrauterine pathologies, throughout the advent of the 'see-and-treat' philosophy, which transferred the advantages of inpatient surgery to the office setting. However, in-office operative hysteroscopy was mainly limited to minor pathology as a supplement to its diagnosis, whereas commonly larger abnormalities were left to be treated in the operating room. Nowadays, pre-surgical assessment of uterine pathology is based on modern ultrasound evaluation and the evolving role of in-office hysteroscopy as a well-planned treatment modality for larger lesions and more complex procedures. Office operative hysteroscopy has been accepted as a feasible, cost-effective, practical way to treat almost any intrauterine disease. Despite the growing role of other imaging tools in the proper evaluation of benign uterine diseases, especially extended beyond to direct hysteroscopic visualization, diagnostic hysteroscopy remains a valuable tool of direct endometrial sampling and may be used as the first line in the diagnosis of endometrial cancer and hyperplasia. Our aim is to describe the most recent innovations and future perspectives in the field of outpatient operative hysteroscopy: mini-resectoscopes, intrauterine morcellators, tissue retrieval systems, diode laser, new miniaturized mechanical instruments, endometrial ablation devices and portable and entry-level hysteroscopes.

Reproductive outcomes of infertile women undergoing "see and treat" office hysteroscopy: a retrospective observational study

INTRODUCTION

This study aimed to assess the feasibility and efficacy of office hysteroscopy to diagnose and treat the specific uterine pathologies frequently diagnosed and thought to be associated with female infertility.

MATERIAL AND METHODS

Using office hysteroscopy, we examined the uterine cavity in women with primary or secondary infertility and evaluated the reproductive outcomes of those affected by one or more pathologies, including cervico-isthmic adhesions, intrauterine polyps and intrauterine adhesions. Additional patient characteristics considered were age and parity, uterine pathology, pain during hysteroscopy, and outcomes including spontaneous pregnancies achieved and time between treatment and pregnancy.

RESULTS

Reproductive outcomes of 200 patients affected by one or more uterine pathologies were evaluated. Cervico-isthmic adhesions were the most frequent findings in older women, with nearly 80% of them achieving pregnancy sooner than the others in our study. Spontaneous pregnancy rates following office hysteroscopy were 76%, 53% and 22% in women with cervico-isthmic adhesions, polyps (< 5 mm) and intrauterine adhesions, respectively.

CONCLUSIONS

Office hysteroscopy is a feasible and highly effective diagnostic and therapeutic procedure for cervico-isthmic and intrauterine adhesions, as well as for small polyps, allowing the resolution of female infertility related to these pathologies, without trauma and with only minimal discomfort.