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Analysis on uterine perforation of hysteroscopic electrosurgeries
Oral Presentations
negative predictive value (NPV) of the hysteroscopic evaluation were calculated in each patient group. Results. Of 925 patients, 573 (62%) were included in group 1 and 352 (38%) in group 2. In groupl, hysteroscopy showed an endometrial abnormality in 105 (18.3%) women. In group 1, comparison of the diagnostic value of hysteroscopy with histology for detecting endometrial abnormalities yielded 99 % sensitivity and 100 % specificity, 100 % PPV and 99 % NPV for hysteroscopy. In group 2, hysteroscopy revealed an endometrial abnormality in 125 (35.5%) women. Comparison in this group of the diagnostic value of hysteroscopy and histology in detecting endometrial abnormalities yielded 100 % sensitivity and 99 % specificity, 98 % PPV and 100 % NPV for hysteroscopy. Corzclusiorz. In our opinion, all postmenopansal women, even if asymptomatic, should undergo regular assessment of the endometrium by hysteroscopy and EGB, especially if taking HRT.
69. Diagnostic Accuracy of Office Hysteroscopy in Postmenopausal Breast Cancer Patients on Tamoxifen 1L Nappi, 1S Bettocchi, 10 Ceci, 2L Selvaggi, 1A Pellegrino, 1R Di Venere, 1V Pansini, 1A Santoro, 1A Santamato. 1University of Bari, Bari, Italy; 2University "Cattolica del Sacro Cuore," Rome, Italy.
Objective. This study was designed in order to assess the diagnostic accuracy of hysteroscopy and the reliability of targeted biopsy, compared with the histological findings after the subsequent hysterectomy in postmenopansal breast cancer patients tan~oxifen-treated. Methods. Thirty-seven breast cancer patients on 20 mg tanloxifen dally therapy who underwent hysteroscopy and, within two months, hysterectomy. Hysteroscopy was performed for abnormal uterine bleeding (AUB) in 15 patients and for ultrasound indication (endometrial thickness) in the others. The age range of the patients was 41 to 80 years. The main indications for hysterectomy were: adenocarcinoma in four cases, atypical hyperplasia in three case, fibroid of the uterus in 14, polyps in 12 and uterine prolapse in four. Duration of tan~oxifen use ranged from 24 to 68 months (mean: 32 months). We compared the hysteroscopic findings (including targeted biopsies) with the histological findings obtained after hysterectomy. The results of this study were then compared with those of a previous one in which we examined the diagnostic accuracy of office hysteroscopy in a general population. Results. Compared with the histological diagnosis of the uterus, the hysteroscopic findings showed a diagnostic sensitivity of 97%, a specificity of 100%, a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 96%. In patients on tan~oxifen the diagnostic accuracy of hysteroscopy is resulted the same that in general population (p = n.s.). Corzclusiorz. Hysteroscopy is confirmed as a powerful diagnostic method for diagnosing endometrial disease because it provides a direct vision of the uterine cavity and reveals focal lesions.
70. Operative Hysteroscopy in Physiological Solution for the Management of Residual Trophoblast A Golan, R Sagiv, S Ginath, M Glezerman. The Edith Wolfson Medical Center, Holon, Israel.
Objective. To demonstrate that operative hysteroscopy can be an excellent method for the removal of retained products of conception. Desigrz. Retrospective study. Settirzg. University affiliated teaching hospital. Patierzts. Fifty two women with retained products of conception. Irzterverztiorz. Operative hysteroscopy was performed in physiological solution by the non-activated loop (versapoin0, using only its mechanical effect. Measuremerzts arzdMairz Results. The procedure was uncomplicated in all cases. The post operative course was unremarkable in all women, with the exception of one case of sepsis in a patient with postpartum residua. Corzclusiorz. Mechanical hysteroscopic resection of retained conceptional tissue is a promising alternative to the traditional treatment of blind sharp curettage of the uterine cavity.
71. Analysis on Uterine Perforation of Hysteroscopic Electrosurgeries E Xia. Fuxing Hospital, Affiliate of Capital University of Medical Sciences Hysteroscopic Center, Beijing, China.
Objective. To estimate the cause, diagnosis, treatment and preventive methods of uterine perforation results in hysteroscopic electrosurgeries. Desigrz. Retrospective evaluation. Settirzg. Two hospitals affiliated of University and three municipal hospitals. Patierzts. Three thousands and forty-one. Interventions hysteroscopic electrosurgeries for benign pathology of uterine cavity. Measuremerzts arzdMairz Results. There were 1468 cases of TCRE, 797 cases of TCRM, 783 cases of TCRP, 189 cases of TCRS, 112 cases of TCRA and 192 cases of TCRF. All operations were performed under B-Ultrasonography or laparoscopy monitoring. Cervical dilator stick was inserted into cervical canal or put Misoprostol 200s in the posterior fornix at the evening before operation. Uterine perforation was divided in two groups: caused by approach (entry-related) and caused by surgical instruments (techniquerelated). Sixteen cases (0.45 %) of uterine perforation were encountered in which 13 cases were complete uterine perforation and 3 cases were incomplete uterine perforations. Seven cases occurred during dilating cervix and 1 case occurred during insetting hysteroscopy. Eight cases were technique-related caused by electrode. Incidences of uterine perforation were: TCRA 4.46%, TCRF 3.13%, TCRE 0.27%, TCRM 0.13%, TCRP and TCRS had no uterine perforation. The 16 cases were all found during operations in time. Ten cases (62.5%) were found by B ultrasound or
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August 2003, Vol. 10, No. 3 Supplement
TheJournal of the American Association of Gynecologic Laparoscopists
laparoscopy, 6 cases (37.5%) were found by hysteroscopy and clinical features. Corzc/usiorz. TCRA and TCRF were more risky. B ultrasound or laparoscopy monitoring during hysteroscopic electrosurgery can make for prevent but cannot avoid uterine perforation.
72. Complications Occurring in Patients Undergoing Operative Hysteroscopy: Relationship of Distension Media to Complications JA Williams, M Cohen. Advanced Women's Health Institute, Denver, Colorado.
Objective. To determine the relationship of complications when normal saline or Ringer's lactate and glycine are used in operative hysteroscopy. Desigrz. Retrospective analysis of 219 patients. Settirzg. Private gynecologic practice. Patierzts. Ages 22-76, who had symptomatic uterine leiomyomas, polyps, or dysfunctional uterine bleeding. Irzterverztiorzs. Hysteroscopic endometrial resection ablation, myomectomy, and polypectomy. Results. Total of 23 (10.50%) patients who had perioperative complications. Twelve (5.48%) patients experienced increased vaginal bleeding requiring placement of a Foley catheter to tamponade the bleeding vessels. Glycine was used in 5 cases, and Ringer's lactate or normal saline was used in seven. Fluid overload, (1850-5950ml), occurred in 7 (3.2%) of the cases. Two of the cases involved the use of glycine. Four cases involved Ringer's lactate or normal saline. The distension media used was not known in one of the cases involving fluid overload. Two of the twenty-two patients had both, fluid overload and increased postoperative vaginal bleeding. Six (2.7%) patients experienced uterine perforation. Glycine was used in three cases. Ringer's lactate or normal saline was used in three of the cases. None required operative laparoscopy. There was no statistical significance noted when comparing the distension media used and the occurrence of complications. Corzclusiorz. The rate of complications occurring in operative hysteroscopic cases in which Ringer's lactate or normal saline is used versus the complications occurring in cases where glycine is used is not statistically significant enough to warrant the use of one form of distension media over another based only on complication rates.
73. Carbon Dioxide Versus Normal Saline in Outpatient Hysteroscopy P Litta, M Bonora, C Pozzan, F Merlin, G Sacco, M Guidolin. Department of Gynecological Sciences and Human Reproduction, Padova, Italy.
Objective. The objective of this study is to measure patients' discomfort after hysteroscopy with CO2 or normal saline. Desigrz. Prospective study of 415 office hysteroscopies with CO2 and normal saline. After hysteroscopy, women were
asked to rate pain they experienced on a 10-cm visual analogue scale (VAS: 0 = no pain, 100 = the worst imaginable pain). Results of pain scores were expressed as mean + SD (0-40 = minimal, 41-70 = moderate, 71-100 = severe). Settirzg. Department of Gynecological Sciences and Human Reproduction, Padova, Italy. Patierzts. Four hundred fifteen patients, after office hysteroscopy, were randomized in two groups according to distension medium (201 CO2 and 214 normal saline). The nature of randomization was to alternate distension media on a weekly basis. Measummerzts arzd Mairz Results. Only in premenopausal status, nulliparous women revealed a significantly higher pelvic discomfort (37.8 + 26.2) compared to multiparous (27.1 + 23.5) (P<0.001). Considering all patients and distension media, pelvic discomfort was generally minimal, resulting higher in normal saline (P<0.05). Corzclusiorz. CO2 and normal saline are comparable for costs and patient's discomfort. Considering high frequency of abnormal uterine bleeding, normal saline should be considered the most appropriate distension medium for outpatient hysteroscopy.
Open Communications 4--Fertility / Adhesions 74. Endometriosis and Endometrial Polyps in Infertile Patients RGM Izquierdo, AA Luciano, GM Roy. Center for Fertility and Reproductive Endocrinology, New Britain General Hospital, New Britain, Connecticut.
Objective. To evaluate the relationship between endometriosis and endometrial polyps in women with infertility. Desigrz arzd Irzterverztiorz. Retrospective analyses of 318 consecutive laparoscopic-hysteroscopic cases for the management of infertility. Settirzg. Tertiary Center for Fertility and Reproductive Surgery Patierzts. Infertile women with pelvic factor infertility. Measummerzts arzd Results. Of 318 infertile women, 197 (61.9%) were diagnosed with endometriosis by laparoscopy and 67 (21.1%) were diagnosed with endometrial polyps by hysteroscopy. Hystology confirmed the clinical diagnosis of endometriosis in 158/197 (80%) of cases and the clinical diagnosis of polyps in 42/67 (62.7%) of cases. Endometrial polyps were found in 15.2% of women with endometriosis but only in 4.7% of women without endometriosis (p<0.01). In women with endometrial polyps, endometriosis was found in in 57.1% of cases (p < 0.01). Corzclusiorz. In infertile women, the presence of endometriosis confers a higher risk for endometrial polyps. Moreover, the presence of endometrial polyps strongly correlates with the presence endometriosis. Therefore, in infertile women with suspicion of either endometriosis or polyps, both laparoscopy and hysteroscopy should be performed, regardless of ultrasound and radiologic findings.
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negative predictive value (NPV) of the hysteroscopic evaluation were calculated in each patient group. Results. Of 925 patients, 573 (62%) were included in group 1 and 352 (38%) in group 2. In groupl, hysteroscopy showed an endometrial abnormality in 105 (18.3%) women. In group 1, comparison of the diagnostic value of hysteroscopy with histology for detecting endometrial abnormalities yielded 99 % sensitivity and 100 % specificity, 100 % PPV and 99 % NPV for hysteroscopy. In group 2, hysteroscopy revealed an endometrial abnormality in 125 (35.5%) women. Comparison in this group of the diagnostic value of hysteroscopy and histology in detecting endometrial abnormalities yielded 100 % sensitivity and 99 % specificity, 98 % PPV and 100 % NPV for hysteroscopy. Corzclusiorz. In our opinion, all postmenopansal women, even if asymptomatic, should undergo regular assessment of the endometrium by hysteroscopy and EGB, especially if taking HRT.
69. Diagnostic Accuracy of Office Hysteroscopy in Postmenopausal Breast Cancer Patients on Tamoxifen 1L Nappi, 1S Bettocchi, 10 Ceci, 2L Selvaggi, 1A Pellegrino, 1R Di Venere, 1V Pansini, 1A Santoro, 1A Santamato. 1University of Bari, Bari, Italy; 2University "Cattolica del Sacro Cuore," Rome, Italy.
Objective. This study was designed in order to assess the diagnostic accuracy of hysteroscopy and the reliability of targeted biopsy, compared with the histological findings after the subsequent hysterectomy in postmenopansal breast cancer patients tan~oxifen-treated. Methods. Thirty-seven breast cancer patients on 20 mg tanloxifen dally therapy who underwent hysteroscopy and, within two months, hysterectomy. Hysteroscopy was performed for abnormal uterine bleeding (AUB) in 15 patients and for ultrasound indication (endometrial thickness) in the others. The age range of the patients was 41 to 80 years. The main indications for hysterectomy were: adenocarcinoma in four cases, atypical hyperplasia in three case, fibroid of the uterus in 14, polyps in 12 and uterine prolapse in four. Duration of tan~oxifen use ranged from 24 to 68 months (mean: 32 months). We compared the hysteroscopic findings (including targeted biopsies) with the histological findings obtained after hysterectomy. The results of this study were then compared with those of a previous one in which we examined the diagnostic accuracy of office hysteroscopy in a general population. Results. Compared with the histological diagnosis of the uterus, the hysteroscopic findings showed a diagnostic sensitivity of 97%, a specificity of 100%, a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 96%. In patients on tan~oxifen the diagnostic accuracy of hysteroscopy is resulted the same that in general population (p = n.s.). Corzclusiorz. Hysteroscopy is confirmed as a powerful diagnostic method for diagnosing endometrial disease because it provides a direct vision of the uterine cavity and reveals focal lesions.
70. Operative Hysteroscopy in Physiological Solution for the Management of Residual Trophoblast A Golan, R Sagiv, S Ginath, M Glezerman. The Edith Wolfson Medical Center, Holon, Israel.
Objective. To demonstrate that operative hysteroscopy can be an excellent method for the removal of retained products of conception. Desigrz. Retrospective study. Settirzg. University affiliated teaching hospital. Patierzts. Fifty two women with retained products of conception. Irzterverztiorz. Operative hysteroscopy was performed in physiological solution by the non-activated loop (versapoin0, using only its mechanical effect. Measuremerzts arzdMairz Results. The procedure was uncomplicated in all cases. The post operative course was unremarkable in all women, with the exception of one case of sepsis in a patient with postpartum residua. Corzclusiorz. Mechanical hysteroscopic resection of retained conceptional tissue is a promising alternative to the traditional treatment of blind sharp curettage of the uterine cavity.
71. Analysis on Uterine Perforation of Hysteroscopic Electrosurgeries E Xia. Fuxing Hospital, Affiliate of Capital University of Medical Sciences Hysteroscopic Center, Beijing, China.
Objective. To estimate the cause, diagnosis, treatment and preventive methods of uterine perforation results in hysteroscopic electrosurgeries. Desigrz. Retrospective evaluation. Settirzg. Two hospitals affiliated of University and three municipal hospitals. Patierzts. Three thousands and forty-one. Interventions hysteroscopic electrosurgeries for benign pathology of uterine cavity. Measuremerzts arzdMairz Results. There were 1468 cases of TCRE, 797 cases of TCRM, 783 cases of TCRP, 189 cases of TCRS, 112 cases of TCRA and 192 cases of TCRF. All operations were performed under B-Ultrasonography or laparoscopy monitoring. Cervical dilator stick was inserted into cervical canal or put Misoprostol 200s in the posterior fornix at the evening before operation. Uterine perforation was divided in two groups: caused by approach (entry-related) and caused by surgical instruments (techniquerelated). Sixteen cases (0.45 %) of uterine perforation were encountered in which 13 cases were complete uterine perforation and 3 cases were incomplete uterine perforations. Seven cases occurred during dilating cervix and 1 case occurred during insetting hysteroscopy. Eight cases were technique-related caused by electrode. Incidences of uterine perforation were: TCRA 4.46%, TCRF 3.13%, TCRE 0.27%, TCRM 0.13%, TCRP and TCRS had no uterine perforation. The 16 cases were all found during operations in time. Ten cases (62.5%) were found by B ultrasound or
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August 2003, Vol. 10, No. 3 Supplement
TheJournal of the American Association of Gynecologic Laparoscopists
laparoscopy, 6 cases (37.5%) were found by hysteroscopy and clinical features. Corzc/usiorz. TCRA and TCRF were more risky. B ultrasound or laparoscopy monitoring during hysteroscopic electrosurgery can make for prevent but cannot avoid uterine perforation.
72. Complications Occurring in Patients Undergoing Operative Hysteroscopy: Relationship of Distension Media to Complications JA Williams, M Cohen. Advanced Women's Health Institute, Denver, Colorado.
Objective. To determine the relationship of complications when normal saline or Ringer's lactate and glycine are used in operative hysteroscopy. Desigrz. Retrospective analysis of 219 patients. Settirzg. Private gynecologic practice. Patierzts. Ages 22-76, who had symptomatic uterine leiomyomas, polyps, or dysfunctional uterine bleeding. Irzterverztiorzs. Hysteroscopic endometrial resection ablation, myomectomy, and polypectomy. Results. Total of 23 (10.50%) patients who had perioperative complications. Twelve (5.48%) patients experienced increased vaginal bleeding requiring placement of a Foley catheter to tamponade the bleeding vessels. Glycine was used in 5 cases, and Ringer's lactate or normal saline was used in seven. Fluid overload, (1850-5950ml), occurred in 7 (3.2%) of the cases. Two of the cases involved the use of glycine. Four cases involved Ringer's lactate or normal saline. The distension media used was not known in one of the cases involving fluid overload. Two of the twenty-two patients had both, fluid overload and increased postoperative vaginal bleeding. Six (2.7%) patients experienced uterine perforation. Glycine was used in three cases. Ringer's lactate or normal saline was used in three of the cases. None required operative laparoscopy. There was no statistical significance noted when comparing the distension media used and the occurrence of complications. Corzclusiorz. The rate of complications occurring in operative hysteroscopic cases in which Ringer's lactate or normal saline is used versus the complications occurring in cases where glycine is used is not statistically significant enough to warrant the use of one form of distension media over another based only on complication rates.
73. Carbon Dioxide Versus Normal Saline in Outpatient Hysteroscopy P Litta, M Bonora, C Pozzan, F Merlin, G Sacco, M Guidolin. Department of Gynecological Sciences and Human Reproduction, Padova, Italy.
Objective. The objective of this study is to measure patients' discomfort after hysteroscopy with CO2 or normal saline. Desigrz. Prospective study of 415 office hysteroscopies with CO2 and normal saline. After hysteroscopy, women were
asked to rate pain they experienced on a 10-cm visual analogue scale (VAS: 0 = no pain, 100 = the worst imaginable pain). Results of pain scores were expressed as mean + SD (0-40 = minimal, 41-70 = moderate, 71-100 = severe). Settirzg. Department of Gynecological Sciences and Human Reproduction, Padova, Italy. Patierzts. Four hundred fifteen patients, after office hysteroscopy, were randomized in two groups according to distension medium (201 CO2 and 214 normal saline). The nature of randomization was to alternate distension media on a weekly basis. Measummerzts arzd Mairz Results. Only in premenopausal status, nulliparous women revealed a significantly higher pelvic discomfort (37.8 + 26.2) compared to multiparous (27.1 + 23.5) (P<0.001). Considering all patients and distension media, pelvic discomfort was generally minimal, resulting higher in normal saline (P<0.05). Corzclusiorz. CO2 and normal saline are comparable for costs and patient's discomfort. Considering high frequency of abnormal uterine bleeding, normal saline should be considered the most appropriate distension medium for outpatient hysteroscopy.
Open Communications 4--Fertility / Adhesions 74. Endometriosis and Endometrial Polyps in Infertile Patients RGM Izquierdo, AA Luciano, GM Roy. Center for Fertility and Reproductive Endocrinology, New Britain General Hospital, New Britain, Connecticut.
Objective. To evaluate the relationship between endometriosis and endometrial polyps in women with infertility. Desigrz arzd Irzterverztiorz. Retrospective analyses of 318 consecutive laparoscopic-hysteroscopic cases for the management of infertility. Settirzg. Tertiary Center for Fertility and Reproductive Surgery Patierzts. Infertile women with pelvic factor infertility. Measummerzts arzd Results. Of 318 infertile women, 197 (61.9%) were diagnosed with endometriosis by laparoscopy and 67 (21.1%) were diagnosed with endometrial polyps by hysteroscopy. Hystology confirmed the clinical diagnosis of endometriosis in 158/197 (80%) of cases and the clinical diagnosis of polyps in 42/67 (62.7%) of cases. Endometrial polyps were found in 15.2% of women with endometriosis but only in 4.7% of women without endometriosis (p<0.01). In women with endometrial polyps, endometriosis was found in in 57.1% of cases (p < 0.01). Corzclusiorz. In infertile women, the presence of endometriosis confers a higher risk for endometrial polyps. Moreover, the presence of endometrial polyps strongly correlates with the presence endometriosis. Therefore, in infertile women with suspicion of either endometriosis or polyps, both laparoscopy and hysteroscopy should be performed, regardless of ultrasound and radiologic findings.
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