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Hysteroscopy: A clinical experience with 320 patients
Hysteroscopy: JOHN
J.
RAFAEL Chicago,
A clinical experience with 320 patients
SCIARRA,
M.D.,
F.
M.D.
VALLE,
PH.D.
Illinois
of
Hysteroscopv has ad&d a neu’ dimension to the management patient, with ~)mrnot~ chnical problems, increasing the accuracv oj diagrzosis and serlling as ati adjunct ill treatment of intrauterine conditions. This report .curnrnarize.r the hysteros~opic experience with 320 selected patients, 104 in the reproductive age group with abrlormal uterine bleeding, 91 who underwent hysteroscopy for location and retrieual sf intrauterine contraceptive devices, 36 with primary or secondary infertility, 36 ullth postmenopausal bleeding, and 15 with uterine leiomyomas. Para&vical block anesthesia ula5 used successfully in 214 patients. General anesthesia was used in the remainder because oj planned additional surgical intervention. Uterine distentiorl was achie-cled with D5W’ in 270 patients, with dpxtran 32% in 30 patients, and ulith COP gas irt.vufJlation in 20 patients. In 71.6 per cent of the patients, visually recognizable or pathologically suspicious intrauterine abnormalities ulere found. This studv further demonstrated the utility of hvsteroscopy in diagnosis of endometrial polyps, uterine .~ubmucous lriomvomas, uterine malformations, and intrauterine adhesions. Hysteroscopv 71~~s al.to helpful~irl taking directed biopsies of selected areas the endometrium in patients with adenomatotc.\ hyperplasia and early adenocarcinoma of the endomrtrium and heljlful iti remozlal intrauterine foreign bodies and evaluation of the recently pregnant uterus xohetl there WN.\ a question of persistent pregnancy. Hysteroscopy is a ,safr ambulatory procrjdur(’ that i~t appealing to both patient and gynecologist in its economy and .simplicity. (AM. J. OBSTET.GYNECOL. 127: 340. 1977.)
qf
of
As A RESULT of technological advances, techniques for intrauterine visualization have progressed rapidly in recent years. Notable among these advances were
From the Departments University of Minnesota Northwestern Unixwsity Presented
before
of Obstetric., and Medical School, Medical School.
the Chicago
Gynecological
the introduction of fiberoptics, which made possible the use of high-intensity proximal light sources, and the development of new approaches for distention of the uterine cavity. Concomitant with advances in instrumentation has been a resurgence of clinical interest in hysteroscopy as a diagnostic and therapeutic adjunct in clinical gynecology. The present report details the experience and evaluates the effectiveness with this endoscopic technique in 320 patients with a variety of common gynecologic conditions.
Gynecology, and Society,
May 21, 1976. Received Revised Accepted Reprint Women’s Superior
for publication October October
June
15,
1976.
I, 1976.
Historical
8, 1976.
requests: John J. Sciamz, M.D., Hospital atzd Materni
review
Although it was Pantaleoni’ who first performed hysteroscopy on a living individual, credit must be given conceptually to Rozzini” in Germany who developed an
Prentice 333 Emt
340
Volume
127
Number
4
Hysteroscopy
endoscope for visualization of internal organs, including the uterine cavity, utilizing candlelight illumination reflected by a concave mirror. Hays,3 in the United States, described a modified instrument used by Fisher. In the nineteenth century, hysteroscopy followed the development of cystoscopy. D&ormeaux,’ sometimes referred ro as the father of endoscopy, presented the first model of a workable cystoscope to the French Academy of Medicine. This was the endoscope used by Pantaleoni,’ with a few modifications added by Cruise.5 In this instrument a reflecting mirror was used with a central perforation for viewing. The light source was an alcohol and turpentine lamp. The greatest advance in early endoscopy, however, is attributed to Nitze,’ who introduced the platinum loop for illumination. This event marked the beginning of practical and useful cystoscopy. Distal incandescent illumination was introduced after 1880. Hysteroscopy did not keep pace with cystoscopy, because of‘ the problems relating to uterine distention and visualization in the presence of uterine bleeding. David’ used an endoscope with a sheath and obturator to avoid marked overdilation of the cervix. His endosc-ope was covered with a transparent cap at the distal end to help in visualization. Heineberg’ and Seymour9 approached the problem of bleeding and uterine distention bv designing instruments with channels for uterine flushing and suction. Normen?’ devoted more than 30 years to designing new instruments for uterine visualization. In his early designs he utilized a transparent plastic tube fitting snugly over the optical instrument for visualization. A modern revival of this technique has been adopted by Parent, Toubas and Doerler” with the contact hysteroscope. In the 1970’s, hysteroscopy was popularized by Edstriim and Fernstriim, ” Lindemann, l3 and Quifiones, Alvarado, and Arnar.” There are many instruments commercially available at present, all of which afford excellent intrauterine visualization. Technical interest is presently focused on procedures for washing or evacuating debris from the uterine cavity and on developments that will allow hysteroscopic visualization in the presence of intrauterine bleeding. Regardless of the instrument, three methods of uterine distention are now available: (I) dextran 32% w/v in dextrose 10% w/v (Hyskon)* as initially proposed by Edstrijm and FernstrGm,” (2) CO* gas insufflation as popularized by Lindemann,13 and (3) dextrose 5% in water (D5W) as an irrigating and distending solution, as proposed by @inones, Alvarado, and Aznar.” *Pharmacia
Laboratories,
Inc.,
Piscataway,
New Jersey.
Table
I. Indications
for hysteroscopy
in 320 patients No.
Presumptive Abnormal
Intrauterine
uterine
diagnosis
bleeding
foreign body-
Postmenopausal bleeding Primary infertility Leiomyomatous uterus with bleeding Suspected uterine anomaly on hysterosalpingogram Secondarv infertilitv Habitual Abortion ’ Tubal catheterization prior to tubal reanastomosis Suspected uterine perforation Possible incomplete removal of products of conception Total
341
of
patients
Per cent
104 95 36 24 18 16
32.5 29.7 11.5 7.5 5.6 4.9
12 8 3
3.7 2.5 0.9
2 2
0.6 0.6
320
100.0
Indications and contraindications The principal indication for diagnostic hysteroscopy is the suspicion of intrauterine pathology. Clinical indications for operative hysteroscopy presently include directed intrauterine biopsy, division of intrauterine adhesions, removal of intrauterine foreign bodies, and cannulation of the tubal ostia.15* I6 Contraindications to the use of the technique are similar to those proposed by early investigators: Recent or present uterine infection, profuse bleeding, and pregnancy. A modified technique has been developed by Agiiero, Aure, and Ldpez” to allow intrauterine visualization when an intrauterine pregnancy exists.
Patients studied and anesthesia used Hysteroscopy was performed in 320 patients, a series representing the authors’ experience in three institutions: The University of Minnesota Hospitals, the Hennepin County General Hospital in Minneapolis, and the Prentice Women’s Hospital and Maternity Center of Northwestern Memorial Hospital in Chicago. Procedures were performed from September, 1973, through April, 1976. The present series includes and expands the authors’ previous series reported in 1975.” The indications for hysteroscopy in these patients are itemized in Table I. The most common indications for hysteroscopy were a history of abnormal uterine bleeding in women during the reproductive years, suspected intrauterine foreign bodies, primary and secondary infertility, and postmenopausal bleeding in older women. The age of the patients ranged from 16 to 75 years, and the mean age was 34 years. Paracervical block anesthesia was used in 214 patients, and general anesthesia was used in the remain-
342
Sciarra
and Vale
Fig. 1. Hysteroscope with the flexible biopsy forceps in place (&or/) ing 106 because of planned additional surgical intervention such as laparoscopy or diagnostic dilatation and curettage. Those patients who had paracervical block anesthesia did not receive any additional analgesia.
Instrumentation and techniques Several different hysteroscopes were used and evaluated during the time of this study. Included were instruments manufactured by Storz,* Wolf,? ACMI,$ and Eder.3 The most commonly and frequently used instrument was the Storz endoscope (Fig. 1). The ACM1 instrument was most commonly used with dextran 32%. The Wolf instrument was used with CO* gas insufflation and required an additional suction cervical adaptor. The Storz hysteroscope was used mainly with D5W for uterine distention, as leas the Eder instrument. With the above instruments the cervix must be dilated to 7 mm. This can easily be accomplished with standard cervical dilators using paracervical block anesthesia as previously described. The Eder hystero*Karl Storz Endoscopy-America, Inc., Los Angeles, California. tRichard Wolf Medical Instruments Corp., Rosemont, Illinois. fAmerican Cystosrope Makers, Inc., Stamford, Connecticut. $Eder Instrument Company. Inc.. Chicago, Illinois.
scope was used as a viewing and operating instrument and requires 8 mm. of cervical dilatation. Uterine distention was achieved lvith D5M’ in 270 patients, with dextran 32% in 30 patients and with CO2 gas insufflation in 20 patients. When (:Os gas insufflation was employed, a Hvsterofiator. designed by Lindemann, was used, achieving a flow of 30 to 60 ml. per minute with a maximum intrauterine pressure of 100 mm. Hg. With this technique, the examination did not exceed 5 minutes. Continuous ECG monitoring and an intravenous catheter were utilized in thtrse patients.
Procedure The patients were evaluated with a clinical history. :I physical examination. and routine cytologic smears. A gonorrhea culture was usually taken and a pregnant! test was performed when appropriate. In premenopausal patients, the examination was performed when possible during the proliferative phase of the menstrual cycle, within 5 to 10 days after the completion of menstruation. Prior to hysteroscopy the procedure was explained to the patient rvith drawings and photographs, and informed consent was obtained. The basic procedure has been described in a pre\ious publication.‘” The following modifications and atlditions are of particular note when the tee hniqur: is performed on an ambulatory basis. Follo\ving an antiseptic vaginal prep, the cervix is visualized and
Volume Number
127 4
paracervical block performed with 1 per cent mepivacaine, utilizing 8 to 10 cc. of the solution on each side. Ten minutes are allowed for the anesthetic to take eftect. When general anesthesia is used, one can proceed directly to cervical dilatation. The uterine cavitv may be sounded with a uterine probe, but this is not essential. Unless the cervix is patulous, it is necessary to progressively dilate the cervical canal to 7 or 8 mm. depending upon the instrument used. The hysteroscope. with its attached light source and irrigating solution or gas connections in place, is introduced. When liquid media are used, the inflow pressures vary with indiljidual patients and with the type of examination or intrauterine manipulation required. When utilizing DSW, a commercially available plastic fluid container is used with an external cuff pressure of 80 to 120 mm. Hg. Three to ,i minutes are generally sufficient for good visualization of the uterine cavity, including the tubal ostin (Fig. 2). At this point, the decision is made for directed biopsies of unusual tissue. polyps, or submu~~ous l&myomas. When the technique is being utilized to retrie\-e “lost” intrauterine devices, or the ca\.ity is found to contain clots or endometrial debris, a polyethylene catheter is used to wash the cavity using loH-pressure irrigation and gravity drainage before complete distention is obtained. This is often necessary for good 1 isualization if a foreign body is present in the uterine cavity. When hysteroscopy is performed under general allesthrsia. it is usually performed prior to additional planned surgical procedures such as laparoscopy. but ir may be performed concurrently or subsequently. Results The hysteroscopic findings in 320 patients are detailed in Table II. In 71.6 per cent of the patients, visually recognizable or pathologically suspicious intrauterine abnormalities were found. A significant number of patients were found with intrauterine pathology which could be related to the symptomatology presented. Endometrial polyps, submucous leiomyomas. foreign bodies, and intrauterine adhesions \verc among the recognizable conditions found. In two patients, a focal adenocarcinoma of the endometrium was visualized, biopsied, and staged for proper therapy. The patients examined for possible incomplete removal of products of conception had undergone a first trimester pregnancy termination with no tissue or questionable villi seen in the curettings and presented with persistently positive pregnancy tests. They underwent examination under anesthesia, uti-
Fig. 2. Hykteroxopic view the uterotubal opening. Table
II. Hysteroscopic
of the normal
findings
Hysteroscopy
343
uterine
and
fundus
in 320 patients No. of
Findings Normal uterine cavity Intrauterine foreign body Endometrial polyps Submucous leiomyoma Uterine septum Intrauterine adhesions Atrophic endometrium Cesarean section scar defect Adenomatous hyperplasia Unilateral uterine horn Tubal catheterization prior to reanastomosis Adenocarcinoma of endometrium Uterine perforation Incomplete removal of products conception Total
patient5
of
PW cent
91 82 65 30 11 11 8 6 5 3 3
28.4 25.6 20.3 9.5 3.4 3.4 2.6 1.9 1.6 0.9 0.9
2 2 1
0.6 0.6 0.3
320
100.0
lizing laparoscopy to rule out ectopic pregnancy. Hysteroscopy was performed when no tubal pathology was found. In an attempt to correlate the preoperative indications with the subsequent hysteroscopic findings, several subgroups were tabulated in greater detail. Table III represents hysteroscopic findings in 104 patients in the reproductive age group who underwent hysteroscopy for abnormal uterine bleeding. In 74 patients (71 per cent), abnormalities were found which could explain the symptomatology. In four patients, a focal lesion which was suspicious of malignancy was de-
344
Sciarra
and Valle
Fig. 3. Illustration of’the hysteroscopic findings in Patient K. M. Hysteroscope uterine cavity. Note lack of tubal opening on the right side.
Table
III.
in the
reproductive
Hysteroscopic
uterine
bleeding
findings age group
in t\ith
104
patients
with
No. ofputiPnts
Normal uterine cavity Endometrial polyps Submucous leiomyoma Uterine septum Cesarean section scar defect Adenomatous hyperplasia Intrauterine adhesions
fined.
Directed
to be
adenomatous
Mrhite
in
most
of
these
areas
hyperplasia. and
shows
proved
These
presented
lesions
a papillary
present
findings
on biopsy Table
appearance
in 36 patients
who
postmenopausal
bleeding.
intrauterine
conditions
in 24 patients
adenocarcinomas
of
(67 was
the
per
cent).
finclings
in 36 patients
bleeding
endometrium
All
of these
per
the
Intrauterine
polyps,
two
divided
were
tion and curettage, except in eight patients ously had had several curettages with normal to bleed.
has been
complementary of infertile (53
found;
Hysteroscopy prior to dilatawho previhistology
eight
patients
examined
One
abnormal
as adenomatous the
findings
of infertility.
in selected
adhesions
patients
in
as a
the evaluation examined,
intrauterine present
in
Hysteros-
infertility
demonstrated
pa-
which
hyperplasia.
hysteroscopic
because
of the
lesion
diagnostic method for patients. Of these 36 patients cent)
19
pathology.
eight
patients
were
hysteroscopically.
Table tients
used
therapy.
a focal
was diagnosed
36 patients un-
replacement to have
V demonstrates
Although
endometrial
both were focal and well differentiated. in this group of patients was performed
continued
was found
were
for
finding
had
on estrogen
tients them
recognizable
common
but
were
copy the
hysteroscopy
Hysteroscopically were
Hysteroscopic
postmenopausal
the
Normal uterine caviq Endometrial polyps iltrophic endometrium Submucous leiomvoma Adenocarcinoma ;,f endometrium Adenomatous hyperplasia
30 42 18 4 ‘4 ,t ?
ulcerations.
IV
derwent
biopsy
color
a few
Table
IV.
within
Fmdit2.g~
Findings
with
Table
abnormal
is shown
VI who
lists
the
underwent
hysteroscopic
findings
examination
because
diagnosed uterine leiomyomas. had submucous leiomyomas. pected intrauterine In our srrirs.
!)I
conditions. patients
of
15 pa-
of clinically
Four of these patients Two others had unsuslqearing
intrauterine
dc-
Volume Number
Hysteroscopy
127 4
345
Fig. 5. Distal tip of broken plastic curette removed from patient.
Fig. 4. Distal fragment of a plastic curette (center) superficially embedded in the myometrium of the uterine fundus. Note the clots surrounding the device at top and at left. vices for contraception underwent hysteroscopy for location and retrieval of the devices. In these instances, there were no visible filaments present upon examination. This series is the subject of a separate report.” In 7X patients, the device was observed in situ and was removed under hysteroscopic control. In the remaining 13 no intrauterine device was seen, and these patients required a single x-ray examination to rule out translocation. In six of these 13, translocation was noted and the device was removed by either laparoscopy or laparotomy. In this series of 320 patients, there were no complications related to hysteroscopic observation. In several instances, hysteroscopy was utilized for unusual conditions. Experiences with two such patients are summarized to illustrate the utility of direct intrauterine visualization. Case reports Case 1. Patient K. M. was a 24-year-old primigravida whose last menstrual period was 11 weeks prior to admission. She underwent a first-trimester abortion by suction curettage of a pregnancy thought to be 10 to 11 weeks’ gestational age. Minimal tissue was obtained and a frozen section showed necrotic tissue but no villi. Subsequently. a pregnancy test was positive. On examination, the uterus was slightly enlarged, and a 4 x 5 cm. right adnexal mass was detected. The patient underwent laparoscopy that revealed a rudimentary uterine horn that suggested the presence of a pregnancy. Concomitant hysteroscopy was performed, showing only fragments of tissue within the uterine cav-
Table V. Hysteroscopic with primary infertility secondary infertility
findings in 24 patients and 12 patients with
Firrding.Y Normal uterine cavity Intrauterine adhesions Endometrial polyps Cesarean section scar defect Submucous leiomyoma Uterine septum
No.
UJpatients
17 8 6 2 2 1
Table VI. Hysteroscopic findings in 15 patients with diagnosed uterine leiomyomas
Normal uterine cavity Submucous leiomyoma Uterine septum Endometrial polyps
ity and no uterine or tubal opening on the right side. The left uterotubal junction and opening, however, were clearly visible (Fig. 3). Exploratory laparotomy was then performed and the right rudimentary horn and attached tube were resected. The specimen contained an early intact ectopic pregnancy. The patient recovered uneventfully. Case 2. Patient H. P. was a 17-year-old woman with a history of two early abortions. The second of these abortions was performed under general anesthesia at 8 weeks’ gestation by suction curettage 6 weeks prior to the present hysteroscopy. At the completion of the curettage, a small fragment of the tip of the plastic curette was missing, apparently having broken off during the procedure. X-rays, repeat curettage, and ultrasonography all failed to disclose an intrauterine foreign body. The hysteroscopy was performed, and
346
Sciarra
February Am. j. Obstet.
and Valle
Fig. 6. Tubal catheterization teroscopic control.
being performed
under hys-
the tip of the plastic curette could be seen partially embedded in the uterine wall at the fundus (Fig. 4). Minor dissection was performed and the plastic piece dislodged and removed transcervically (Fig. 5).
Endoscopic intrauterine visualization has added a new dimension to the management of patients with common clinical problems. Hysteroscopy increases the accuracy of clinical diagnosis and may serve as an adjunct in the treatment of patients with specific intrauterine pathologic conditions. As stated in our previous report, “Hysteroscopy does not supplant other diagnostic procedures; rather, it complements them.“” The present study has indicated the utility of this technique in the diagnosis of endometrial polyps, uterine submucous leiomyomas, uterine malformations, and intrauterine adhesions. It has also demonstrated the utility of the technique in taking directed biopsies of selected areas of the endometrium in patients with adenomatous hyperplasia and early adenocarcinoma of the endometrium, and has drawn attention to the advantages of utilizing hysteroscopy in the removal of intrauterine foreign bodies and the evaluation of the recently pregnant uterus in which there is the question of persistent pregnancy. The results of this study confirm and extend the conclusions of our previous report. ” Our experience parallels that of other investigators who have evaluated the utility of hysteroscopy in the clinical setting. Many hvstcroscopic instruments are now commer-
1.5. 1977 Gynrc~,l.
cially available, and the technique can now be performed safely and effectively in most institutions. Cmtion, however, must be used in the proper selection of patients, the type of anesthesia, and the medium for uterine distention. Familiarity with the instrumentation and the procedure is essential. The technique has been completely and thoroughly described in a rec’ent monograph by Neuwirth.ig Hysteroscopy requires the usual safeguards of any endoscopic procedure, partic LIlarly in relation to the various liquid and gas media used for uterine distention. D5W is readily available. and appears to be a safe and effective fluid for in trauterine use. Visualization, however. is somewhat more difficult, particularly if bleeding is present. Dcstran 32%, W/V gives particularly high-quality visualization. With the use of dextran. it is advisable to have an intravenous line available, because of the rare possibility of an anaphylactic reaction to the polysaccharide.‘” CO2 gas insufflation with a Hysteroflator also gives excellent visualization, but requires the rem I\ al of mucus and debris from the uterine ca\,ity, if maximal clarity is to be obtained. One must be particularlv cautious with COZ to pay attention to the proper pressure-flow relationships, as described by l.itidemann.‘” It should be stressed that in acquiring c\perience with hysteroscopy initial examinations should be done on multiparous women with no uteritie pathology. Once skill in intrauterine visualization Ira\ been acquired, the technique can be used for diagnosis and for correlation of intrauterine findings with hyterosalpingographic findings or findings on rubsequent curettage. Intrauterine surgical intervention or manipulation should not be undertaken as a lrrimary step in hysteroscopy. This is partirutarly important when the uterotubat junction is to he approached for surgical intervention, such as catheterization or introduction of probes or electrodes. Intrauterine surgical intervention as well as dissections, etectrosurgerv. removal of septa, or dissection of pedunculated submucous leiomyomas should be left fin- the esperienced hysteroscopist. Several common clinical situations encountered in this series of patients merit further discussion. The present series includes 91 patients wearing intrauterine devices for contraception who underwent hysteroscopy, for location and retrieval of the devices. In these instances, there were no visible filaments present on examination. While this series is the subject of a scparate report, ” it is particularly noteworthy that att 01 these procedures were performed under paracervicxl block except for six for whom additional surgery was planned. For the location and removal of intrauterine coin-
Volume 127 Number
Hysteroscopy
347
4
traceptive devices, local paracervical block has proved to be sufficient and satisfactory. Excessive intrauterine distention is not necessary and uterotubal sphincter mechanism may protect against extensive peritoneal spillage of the irrigating fluid. In these patients, the use of x-rays to the pelvic area was decreased, and blind uncomfortable manipulations for intrauterine device location and removal were avoided. Hysteroscopy thus offers a valuable alternative method of management of the patient with the “lost” intrauterine device or the intrauterine device with “missing” filaments.“’ 23 We have also found hysteroscopy to be useful in the evaluation of the infertile female. In 36 patients reported in this series, hysteroscopy served as a complementary diagnostic measure. Of these 36 patients examined, 19 (53 per cent) demonstrated intrauterine pathology. In eight patients who demonstrated intrauterine adhesions, these were divided under hysterby oscopic view. In two patients this was accomplished simple distention of the cavity and mechanical division, and the remaining patients required electrosurgery. Three patients in the series with primary infertility of more than 5 years’ duration whose hysteroscopic findings were essentially normal achieved a pregnancy after the procedure, one in the same cycle and two within three cycles of the hysteroscopy. While these pregnancies may be circumstantial, it is tempting to speculate that the uterine distention and the hydrotubation might be related. Hysteroscopy may offer an aid in tubal surgery by allowing the operator to pass catheters transcervically through the interstitial portion of the oviducts into the tubal isthmus or ampulla (Fig. 6). This is useful in tubal reconstructive surgery when reanastomosis is planned. This technique has been used successfully in several patients in this series. The proximal ends of the catheters are then left in a coiled fashion within the uterine
cavity and removed subsequently by hysteroscopy after tubal healing has occurred. More experience with this procedure is necessary before firm conclusions can be drawn as to its utility as an adjunct in tubal reconstructive surgery. While hysteroscopic sterilization by electrocoagulation is an attractive technique since it can be done on an ambulatory basis under local anesthesia, the results have been disappointing. 24 Difficulties in occluding the interstitial portion of the Fallopian tubes have resulted in high failure rates for this procedure. More serious than the failures, however, are recently reported complications associated with electrocoagulation at hysteroscopy.” In a recent collaborative study of the use of hysteroscopic sterilization procedures at 10 centers from the United States, Thailand, West Germany, India, and Singapore, 773 cases were reviewed by Darabi and RichartZ6 The individual series ranged in size from six to 298 cases. Preliminary findings indicate that the over-all failure rate was approximately 36 per cent. although the failure rate in selected series was substantially less. The morbidity statistics indicated that 5.2 per cent of the patients suffered minor complications and 3.2 per cent developed major complications. These included uterine perforations, peritonitis, ectopic pregnancies, and intestinal injuries. In addition, deaths have been reported due to unrecognized major complications. Accordingly, more experience with operative hysteroscopy is necessary before the safety of intrauterine surgery is established. It is possible today to utilize hysteroscopy as an adjunct in the diagnosis of intrauterine pathology. Its applicability as a safe ambulatory procedure makes it an appealing technique for the gynecologist to use in the diagnosis and treatment of common clinical conditions. Its economy and simplicity as well as its positive patient acceptance indicate that it should have a promising future.
REFERENCES 1. Pantaleoni. D. C.: On endoscopic examination of the cavity of the womb, Med. Press. Circ. 8: 26, 1869. 2. Bozzini, P.: Der Lichtleiter, Weimar, 1807, Pearlman, S. J., and Murdock, L. B., Translators, Q. Bull. Northwest. Univ. Med. School 23: 332, 1949. 3. Hays, I.: Instruments of illuminating dark cavities (Note on Fisher, J. D., Boston, and his endoscope), Phil. J. Med. Phys. Sci. 14: 409, 1827. 4. Desormeaux, A. J.: De I’endoscope et de ses applications au diagnostic et au traitment des affections de I’urethre et de la vessie, Paris, 1865, J. B. Baillitre et Fils. 5. Cruise, F. R.: The utility of the endoscope as an aid in the diagnosis and treatment of disease, Dublin Q. J. Med. Sci. 39: 329, 1865. 6. Nitze. M.: Eine neue Beleuchtungs- und Untersuch-
ungs-Methode fiir Harnriihre, Harnblase und Rectum, Wein. Med. Wochenschr. 29: 649, 1879. David, Ch.: L’endoscopie uterine (hysteroscopie). Applications au diagnostic et au traitment des affections intrauterines, Paris, 1908. G. Jacques. Heineberg, A.: Uterine endoscopy; an aid to precision in the diagnosis of intra-uterine disease. A preliminary report, with the presentation of a new uteroscope, Surg. Gynecol. Obstet. 18: 513, 1914. Seymour, H. F.: Endoscopy of the uterus: With a description of a hysteroscope, J. Obstet. Gynecol. Br. Commonw-. 33: 52, 1926. Norment, W. B.: A method of study of the uterine canal, South. Surg. 13: 885, 1947. Parent, B., Toubas, C., and Doerler, B.: L’hysteroscopie decontact, J. Gynecol. Obstet. Biol. Reprod. 3: 511, 1974.
7. 8.
9. 10. 11.
348
Sciarra
and Valle
12. Edstrom, K., and Fernstrdm. I.: The diagnostic possibilities of a modified hysteroscopic technique, Acta Obstet. Gynecol. &and. 49: 327, 1970. 13. Lindemann, H-I.: Transuterine tubal sterilization by CO, hysteroscopy, ir;Sciarra, J. J., Butler, J. C.. and Speidel, J. I.. editors: Hvsteroscooic Sterilization. New York, 1974.
20. Joelsson, 1.: Personal communication, November. 1975. D. UT.: Hysterl>21. Valle, R. F., Sciarra, J. J,, and Freeman, scopic removal of intrauterine devices with missing lilaments, Obstet. Gynecol. In press. D. W.: Hysteroscopy in the 22. Valle. R. F.. and Freeman, localization and removal of intrauterine devices nith “missing strings,” Contraception 11: 161, 1975. 23. Valle. R. F.. and Freeman. D. W.: Hvsteroscopy in tlica management of the “lost” intrauterine device, Advances in Planned Parenthood, Excerpta Medica 10: 164. 1975. research in male and female sterili24. Sciarra. J. J.: Current zation in Schima, M. E., and Lubell, I., editors: New Advances in Sterilization, The Third International Conference on Voluntary Sterilization, Tunis, Tunisia, Frbruary l-4. 1976. New York, 1976, The Association for Voluntary Sterilization, Inc., pp. 189-203. Ch.. and Phaosavasdi. S.: Hysteroscopir 25. Israngkun. sterilization: Complications in 296 cases. in Sciarra, J. .J Droegemueller, W., and Speidel. J. J., editors, Advances in Female Sterilization Techniques, Hagerstown. Maryland, 1976, Harper & Row Publishers, Inc.. pp. 148-152. 26. Darabi. K. F., and Richart, R. M.: Collaborativ-e study on hysteroscopic sterilization prtrcedures: Preliminarv rcport, Obstet. Gynecol. In press. .
I
J.
RAFAEL Chicago,
A clinical experience with 320 patients
SCIARRA,
M.D.,
F.
M.D.
VALLE,
PH.D.
Illinois
of
Hysteroscopv has ad&d a neu’ dimension to the management patient, with ~)mrnot~ chnical problems, increasing the accuracv oj diagrzosis and serlling as ati adjunct ill treatment of intrauterine conditions. This report .curnrnarize.r the hysteros~opic experience with 320 selected patients, 104 in the reproductive age group with abrlormal uterine bleeding, 91 who underwent hysteroscopy for location and retrieual sf intrauterine contraceptive devices, 36 with primary or secondary infertility, 36 ullth postmenopausal bleeding, and 15 with uterine leiomyomas. Para&vical block anesthesia ula5 used successfully in 214 patients. General anesthesia was used in the remainder because oj planned additional surgical intervention. Uterine distentiorl was achie-cled with D5W’ in 270 patients, with dpxtran 32% in 30 patients, and ulith COP gas irt.vufJlation in 20 patients. In 71.6 per cent of the patients, visually recognizable or pathologically suspicious intrauterine abnormalities ulere found. This studv further demonstrated the utility of hvsteroscopy in diagnosis of endometrial polyps, uterine .~ubmucous lriomvomas, uterine malformations, and intrauterine adhesions. Hysteroscopv 71~~s al.to helpful~irl taking directed biopsies of selected areas the endometrium in patients with adenomatotc.\ hyperplasia and early adenocarcinoma of the endomrtrium and heljlful iti remozlal intrauterine foreign bodies and evaluation of the recently pregnant uterus xohetl there WN.\ a question of persistent pregnancy. Hysteroscopy is a ,safr ambulatory procrjdur(’ that i~t appealing to both patient and gynecologist in its economy and .simplicity. (AM. J. OBSTET.GYNECOL. 127: 340. 1977.)
qf
of
As A RESULT of technological advances, techniques for intrauterine visualization have progressed rapidly in recent years. Notable among these advances were
From the Departments University of Minnesota Northwestern Unixwsity Presented
before
of Obstetric., and Medical School, Medical School.
the Chicago
Gynecological
the introduction of fiberoptics, which made possible the use of high-intensity proximal light sources, and the development of new approaches for distention of the uterine cavity. Concomitant with advances in instrumentation has been a resurgence of clinical interest in hysteroscopy as a diagnostic and therapeutic adjunct in clinical gynecology. The present report details the experience and evaluates the effectiveness with this endoscopic technique in 320 patients with a variety of common gynecologic conditions.
Gynecology, and Society,
May 21, 1976. Received Revised Accepted Reprint Women’s Superior
for publication October October
June
15,
1976.
I, 1976.
Historical
8, 1976.
requests: John J. Sciamz, M.D., Hospital atzd Materni
review
Although it was Pantaleoni’ who first performed hysteroscopy on a living individual, credit must be given conceptually to Rozzini” in Germany who developed an
Prentice 333 Emt
340
Volume
127
Number
4
Hysteroscopy
endoscope for visualization of internal organs, including the uterine cavity, utilizing candlelight illumination reflected by a concave mirror. Hays,3 in the United States, described a modified instrument used by Fisher. In the nineteenth century, hysteroscopy followed the development of cystoscopy. D&ormeaux,’ sometimes referred ro as the father of endoscopy, presented the first model of a workable cystoscope to the French Academy of Medicine. This was the endoscope used by Pantaleoni,’ with a few modifications added by Cruise.5 In this instrument a reflecting mirror was used with a central perforation for viewing. The light source was an alcohol and turpentine lamp. The greatest advance in early endoscopy, however, is attributed to Nitze,’ who introduced the platinum loop for illumination. This event marked the beginning of practical and useful cystoscopy. Distal incandescent illumination was introduced after 1880. Hysteroscopy did not keep pace with cystoscopy, because of‘ the problems relating to uterine distention and visualization in the presence of uterine bleeding. David’ used an endoscope with a sheath and obturator to avoid marked overdilation of the cervix. His endosc-ope was covered with a transparent cap at the distal end to help in visualization. Heineberg’ and Seymour9 approached the problem of bleeding and uterine distention bv designing instruments with channels for uterine flushing and suction. Normen?’ devoted more than 30 years to designing new instruments for uterine visualization. In his early designs he utilized a transparent plastic tube fitting snugly over the optical instrument for visualization. A modern revival of this technique has been adopted by Parent, Toubas and Doerler” with the contact hysteroscope. In the 1970’s, hysteroscopy was popularized by Edstriim and Fernstriim, ” Lindemann, l3 and Quifiones, Alvarado, and Arnar.” There are many instruments commercially available at present, all of which afford excellent intrauterine visualization. Technical interest is presently focused on procedures for washing or evacuating debris from the uterine cavity and on developments that will allow hysteroscopic visualization in the presence of intrauterine bleeding. Regardless of the instrument, three methods of uterine distention are now available: (I) dextran 32% w/v in dextrose 10% w/v (Hyskon)* as initially proposed by Edstrijm and FernstrGm,” (2) CO* gas insufflation as popularized by Lindemann,13 and (3) dextrose 5% in water (D5W) as an irrigating and distending solution, as proposed by @inones, Alvarado, and Aznar.” *Pharmacia
Laboratories,
Inc.,
Piscataway,
New Jersey.
Table
I. Indications
for hysteroscopy
in 320 patients No.
Presumptive Abnormal
Intrauterine
uterine
diagnosis
bleeding
foreign body-
Postmenopausal bleeding Primary infertility Leiomyomatous uterus with bleeding Suspected uterine anomaly on hysterosalpingogram Secondarv infertilitv Habitual Abortion ’ Tubal catheterization prior to tubal reanastomosis Suspected uterine perforation Possible incomplete removal of products of conception Total
341
of
patients
Per cent
104 95 36 24 18 16
32.5 29.7 11.5 7.5 5.6 4.9
12 8 3
3.7 2.5 0.9
2 2
0.6 0.6
320
100.0
Indications and contraindications The principal indication for diagnostic hysteroscopy is the suspicion of intrauterine pathology. Clinical indications for operative hysteroscopy presently include directed intrauterine biopsy, division of intrauterine adhesions, removal of intrauterine foreign bodies, and cannulation of the tubal ostia.15* I6 Contraindications to the use of the technique are similar to those proposed by early investigators: Recent or present uterine infection, profuse bleeding, and pregnancy. A modified technique has been developed by Agiiero, Aure, and Ldpez” to allow intrauterine visualization when an intrauterine pregnancy exists.
Patients studied and anesthesia used Hysteroscopy was performed in 320 patients, a series representing the authors’ experience in three institutions: The University of Minnesota Hospitals, the Hennepin County General Hospital in Minneapolis, and the Prentice Women’s Hospital and Maternity Center of Northwestern Memorial Hospital in Chicago. Procedures were performed from September, 1973, through April, 1976. The present series includes and expands the authors’ previous series reported in 1975.” The indications for hysteroscopy in these patients are itemized in Table I. The most common indications for hysteroscopy were a history of abnormal uterine bleeding in women during the reproductive years, suspected intrauterine foreign bodies, primary and secondary infertility, and postmenopausal bleeding in older women. The age of the patients ranged from 16 to 75 years, and the mean age was 34 years. Paracervical block anesthesia was used in 214 patients, and general anesthesia was used in the remain-
342
Sciarra
and Vale
Fig. 1. Hysteroscope with the flexible biopsy forceps in place (&or/) ing 106 because of planned additional surgical intervention such as laparoscopy or diagnostic dilatation and curettage. Those patients who had paracervical block anesthesia did not receive any additional analgesia.
Instrumentation and techniques Several different hysteroscopes were used and evaluated during the time of this study. Included were instruments manufactured by Storz,* Wolf,? ACMI,$ and Eder.3 The most commonly and frequently used instrument was the Storz endoscope (Fig. 1). The ACM1 instrument was most commonly used with dextran 32%. The Wolf instrument was used with CO* gas insufflation and required an additional suction cervical adaptor. The Storz hysteroscope was used mainly with D5W for uterine distention, as leas the Eder instrument. With the above instruments the cervix must be dilated to 7 mm. This can easily be accomplished with standard cervical dilators using paracervical block anesthesia as previously described. The Eder hystero*Karl Storz Endoscopy-America, Inc., Los Angeles, California. tRichard Wolf Medical Instruments Corp., Rosemont, Illinois. fAmerican Cystosrope Makers, Inc., Stamford, Connecticut. $Eder Instrument Company. Inc.. Chicago, Illinois.
scope was used as a viewing and operating instrument and requires 8 mm. of cervical dilatation. Uterine distention was achieved lvith D5M’ in 270 patients, with dextran 32% in 30 patients and with CO2 gas insufflation in 20 patients. When (:Os gas insufflation was employed, a Hvsterofiator. designed by Lindemann, was used, achieving a flow of 30 to 60 ml. per minute with a maximum intrauterine pressure of 100 mm. Hg. With this technique, the examination did not exceed 5 minutes. Continuous ECG monitoring and an intravenous catheter were utilized in thtrse patients.
Procedure The patients were evaluated with a clinical history. :I physical examination. and routine cytologic smears. A gonorrhea culture was usually taken and a pregnant! test was performed when appropriate. In premenopausal patients, the examination was performed when possible during the proliferative phase of the menstrual cycle, within 5 to 10 days after the completion of menstruation. Prior to hysteroscopy the procedure was explained to the patient rvith drawings and photographs, and informed consent was obtained. The basic procedure has been described in a pre\ious publication.‘” The following modifications and atlditions are of particular note when the tee hniqur: is performed on an ambulatory basis. Follo\ving an antiseptic vaginal prep, the cervix is visualized and
Volume Number
127 4
paracervical block performed with 1 per cent mepivacaine, utilizing 8 to 10 cc. of the solution on each side. Ten minutes are allowed for the anesthetic to take eftect. When general anesthesia is used, one can proceed directly to cervical dilatation. The uterine cavitv may be sounded with a uterine probe, but this is not essential. Unless the cervix is patulous, it is necessary to progressively dilate the cervical canal to 7 or 8 mm. depending upon the instrument used. The hysteroscope. with its attached light source and irrigating solution or gas connections in place, is introduced. When liquid media are used, the inflow pressures vary with indiljidual patients and with the type of examination or intrauterine manipulation required. When utilizing DSW, a commercially available plastic fluid container is used with an external cuff pressure of 80 to 120 mm. Hg. Three to ,i minutes are generally sufficient for good visualization of the uterine cavity, including the tubal ostin (Fig. 2). At this point, the decision is made for directed biopsies of unusual tissue. polyps, or submu~~ous l&myomas. When the technique is being utilized to retrie\-e “lost” intrauterine devices, or the ca\.ity is found to contain clots or endometrial debris, a polyethylene catheter is used to wash the cavity using loH-pressure irrigation and gravity drainage before complete distention is obtained. This is often necessary for good 1 isualization if a foreign body is present in the uterine cavity. When hysteroscopy is performed under general allesthrsia. it is usually performed prior to additional planned surgical procedures such as laparoscopy. but ir may be performed concurrently or subsequently. Results The hysteroscopic findings in 320 patients are detailed in Table II. In 71.6 per cent of the patients, visually recognizable or pathologically suspicious intrauterine abnormalities were found. A significant number of patients were found with intrauterine pathology which could be related to the symptomatology presented. Endometrial polyps, submucous leiomyomas. foreign bodies, and intrauterine adhesions \verc among the recognizable conditions found. In two patients, a focal adenocarcinoma of the endometrium was visualized, biopsied, and staged for proper therapy. The patients examined for possible incomplete removal of products of conception had undergone a first trimester pregnancy termination with no tissue or questionable villi seen in the curettings and presented with persistently positive pregnancy tests. They underwent examination under anesthesia, uti-
Fig. 2. Hykteroxopic view the uterotubal opening. Table
II. Hysteroscopic
of the normal
findings
Hysteroscopy
343
uterine
and
fundus
in 320 patients No. of
Findings Normal uterine cavity Intrauterine foreign body Endometrial polyps Submucous leiomyoma Uterine septum Intrauterine adhesions Atrophic endometrium Cesarean section scar defect Adenomatous hyperplasia Unilateral uterine horn Tubal catheterization prior to reanastomosis Adenocarcinoma of endometrium Uterine perforation Incomplete removal of products conception Total
patient5
of
PW cent
91 82 65 30 11 11 8 6 5 3 3
28.4 25.6 20.3 9.5 3.4 3.4 2.6 1.9 1.6 0.9 0.9
2 2 1
0.6 0.6 0.3
320
100.0
lizing laparoscopy to rule out ectopic pregnancy. Hysteroscopy was performed when no tubal pathology was found. In an attempt to correlate the preoperative indications with the subsequent hysteroscopic findings, several subgroups were tabulated in greater detail. Table III represents hysteroscopic findings in 104 patients in the reproductive age group who underwent hysteroscopy for abnormal uterine bleeding. In 74 patients (71 per cent), abnormalities were found which could explain the symptomatology. In four patients, a focal lesion which was suspicious of malignancy was de-
344
Sciarra
and Valle
Fig. 3. Illustration of’the hysteroscopic findings in Patient K. M. Hysteroscope uterine cavity. Note lack of tubal opening on the right side.
Table
III.
in the
reproductive
Hysteroscopic
uterine
bleeding
findings age group
in t\ith
104
patients
with
No. ofputiPnts
Normal uterine cavity Endometrial polyps Submucous leiomyoma Uterine septum Cesarean section scar defect Adenomatous hyperplasia Intrauterine adhesions
fined.
Directed
to be
adenomatous
Mrhite
in
most
of
these
areas
hyperplasia. and
shows
proved
These
presented
lesions
a papillary
present
findings
on biopsy Table
appearance
in 36 patients
who
postmenopausal
bleeding.
intrauterine
conditions
in 24 patients
adenocarcinomas
of
(67 was
the
per
cent).
finclings
in 36 patients
bleeding
endometrium
All
of these
per
the
Intrauterine
polyps,
two
divided
were
tion and curettage, except in eight patients ously had had several curettages with normal to bleed.
has been
complementary of infertile (53
found;
Hysteroscopy prior to dilatawho previhistology
eight
patients
examined
One
abnormal
as adenomatous the
findings
of infertility.
in selected
adhesions
patients
in
as a
the evaluation examined,
intrauterine present
in
Hysteros-
infertility
demonstrated
pa-
which
hyperplasia.
hysteroscopic
because
of the
lesion
diagnostic method for patients. Of these 36 patients cent)
19
pathology.
eight
patients
were
hysteroscopically.
Table tients
used
therapy.
a focal
was diagnosed
36 patients un-
replacement to have
V demonstrates
Although
endometrial
both were focal and well differentiated. in this group of patients was performed
continued
was found
were
for
finding
had
on estrogen
tients them
recognizable
common
but
were
copy the
hysteroscopy
Hysteroscopically were
Hysteroscopic
postmenopausal
the
Normal uterine caviq Endometrial polyps iltrophic endometrium Submucous leiomvoma Adenocarcinoma ;,f endometrium Adenomatous hyperplasia
30 42 18 4 ‘4 ,t ?
ulcerations.
IV
derwent
biopsy
color
a few
Table
IV.
within
Fmdit2.g~
Findings
with
Table
abnormal
is shown
VI who
lists
the
underwent
hysteroscopic
findings
examination
because
diagnosed uterine leiomyomas. had submucous leiomyomas. pected intrauterine In our srrirs.
!)I
conditions. patients
of
15 pa-
of clinically
Four of these patients Two others had unsuslqearing
intrauterine
dc-
Volume Number
Hysteroscopy
127 4
345
Fig. 5. Distal tip of broken plastic curette removed from patient.
Fig. 4. Distal fragment of a plastic curette (center) superficially embedded in the myometrium of the uterine fundus. Note the clots surrounding the device at top and at left. vices for contraception underwent hysteroscopy for location and retrieval of the devices. In these instances, there were no visible filaments present upon examination. This series is the subject of a separate report.” In 7X patients, the device was observed in situ and was removed under hysteroscopic control. In the remaining 13 no intrauterine device was seen, and these patients required a single x-ray examination to rule out translocation. In six of these 13, translocation was noted and the device was removed by either laparoscopy or laparotomy. In this series of 320 patients, there were no complications related to hysteroscopic observation. In several instances, hysteroscopy was utilized for unusual conditions. Experiences with two such patients are summarized to illustrate the utility of direct intrauterine visualization. Case reports Case 1. Patient K. M. was a 24-year-old primigravida whose last menstrual period was 11 weeks prior to admission. She underwent a first-trimester abortion by suction curettage of a pregnancy thought to be 10 to 11 weeks’ gestational age. Minimal tissue was obtained and a frozen section showed necrotic tissue but no villi. Subsequently. a pregnancy test was positive. On examination, the uterus was slightly enlarged, and a 4 x 5 cm. right adnexal mass was detected. The patient underwent laparoscopy that revealed a rudimentary uterine horn that suggested the presence of a pregnancy. Concomitant hysteroscopy was performed, showing only fragments of tissue within the uterine cav-
Table V. Hysteroscopic with primary infertility secondary infertility
findings in 24 patients and 12 patients with
Firrding.Y Normal uterine cavity Intrauterine adhesions Endometrial polyps Cesarean section scar defect Submucous leiomyoma Uterine septum
No.
UJpatients
17 8 6 2 2 1
Table VI. Hysteroscopic findings in 15 patients with diagnosed uterine leiomyomas
Normal uterine cavity Submucous leiomyoma Uterine septum Endometrial polyps
ity and no uterine or tubal opening on the right side. The left uterotubal junction and opening, however, were clearly visible (Fig. 3). Exploratory laparotomy was then performed and the right rudimentary horn and attached tube were resected. The specimen contained an early intact ectopic pregnancy. The patient recovered uneventfully. Case 2. Patient H. P. was a 17-year-old woman with a history of two early abortions. The second of these abortions was performed under general anesthesia at 8 weeks’ gestation by suction curettage 6 weeks prior to the present hysteroscopy. At the completion of the curettage, a small fragment of the tip of the plastic curette was missing, apparently having broken off during the procedure. X-rays, repeat curettage, and ultrasonography all failed to disclose an intrauterine foreign body. The hysteroscopy was performed, and
346
Sciarra
February Am. j. Obstet.
and Valle
Fig. 6. Tubal catheterization teroscopic control.
being performed
under hys-
the tip of the plastic curette could be seen partially embedded in the uterine wall at the fundus (Fig. 4). Minor dissection was performed and the plastic piece dislodged and removed transcervically (Fig. 5).
Endoscopic intrauterine visualization has added a new dimension to the management of patients with common clinical problems. Hysteroscopy increases the accuracy of clinical diagnosis and may serve as an adjunct in the treatment of patients with specific intrauterine pathologic conditions. As stated in our previous report, “Hysteroscopy does not supplant other diagnostic procedures; rather, it complements them.“” The present study has indicated the utility of this technique in the diagnosis of endometrial polyps, uterine submucous leiomyomas, uterine malformations, and intrauterine adhesions. It has also demonstrated the utility of the technique in taking directed biopsies of selected areas of the endometrium in patients with adenomatous hyperplasia and early adenocarcinoma of the endometrium, and has drawn attention to the advantages of utilizing hysteroscopy in the removal of intrauterine foreign bodies and the evaluation of the recently pregnant uterus in which there is the question of persistent pregnancy. The results of this study confirm and extend the conclusions of our previous report. ” Our experience parallels that of other investigators who have evaluated the utility of hysteroscopy in the clinical setting. Many hvstcroscopic instruments are now commer-
1.5. 1977 Gynrc~,l.
cially available, and the technique can now be performed safely and effectively in most institutions. Cmtion, however, must be used in the proper selection of patients, the type of anesthesia, and the medium for uterine distention. Familiarity with the instrumentation and the procedure is essential. The technique has been completely and thoroughly described in a rec’ent monograph by Neuwirth.ig Hysteroscopy requires the usual safeguards of any endoscopic procedure, partic LIlarly in relation to the various liquid and gas media used for uterine distention. D5W is readily available. and appears to be a safe and effective fluid for in trauterine use. Visualization, however. is somewhat more difficult, particularly if bleeding is present. Dcstran 32%, W/V gives particularly high-quality visualization. With the use of dextran. it is advisable to have an intravenous line available, because of the rare possibility of an anaphylactic reaction to the polysaccharide.‘” CO2 gas insufflation with a Hysteroflator also gives excellent visualization, but requires the rem I\ al of mucus and debris from the uterine ca\,ity, if maximal clarity is to be obtained. One must be particularlv cautious with COZ to pay attention to the proper pressure-flow relationships, as described by l.itidemann.‘” It should be stressed that in acquiring c\perience with hysteroscopy initial examinations should be done on multiparous women with no uteritie pathology. Once skill in intrauterine visualization Ira\ been acquired, the technique can be used for diagnosis and for correlation of intrauterine findings with hyterosalpingographic findings or findings on rubsequent curettage. Intrauterine surgical intervention or manipulation should not be undertaken as a lrrimary step in hysteroscopy. This is partirutarly important when the uterotubat junction is to he approached for surgical intervention, such as catheterization or introduction of probes or electrodes. Intrauterine surgical intervention as well as dissections, etectrosurgerv. removal of septa, or dissection of pedunculated submucous leiomyomas should be left fin- the esperienced hysteroscopist. Several common clinical situations encountered in this series of patients merit further discussion. The present series includes 91 patients wearing intrauterine devices for contraception who underwent hysteroscopy, for location and retrieval of the devices. In these instances, there were no visible filaments present on examination. While this series is the subject of a scparate report, ” it is particularly noteworthy that att 01 these procedures were performed under paracervicxl block except for six for whom additional surgery was planned. For the location and removal of intrauterine coin-
Volume 127 Number
Hysteroscopy
347
4
traceptive devices, local paracervical block has proved to be sufficient and satisfactory. Excessive intrauterine distention is not necessary and uterotubal sphincter mechanism may protect against extensive peritoneal spillage of the irrigating fluid. In these patients, the use of x-rays to the pelvic area was decreased, and blind uncomfortable manipulations for intrauterine device location and removal were avoided. Hysteroscopy thus offers a valuable alternative method of management of the patient with the “lost” intrauterine device or the intrauterine device with “missing” filaments.“’ 23 We have also found hysteroscopy to be useful in the evaluation of the infertile female. In 36 patients reported in this series, hysteroscopy served as a complementary diagnostic measure. Of these 36 patients examined, 19 (53 per cent) demonstrated intrauterine pathology. In eight patients who demonstrated intrauterine adhesions, these were divided under hysterby oscopic view. In two patients this was accomplished simple distention of the cavity and mechanical division, and the remaining patients required electrosurgery. Three patients in the series with primary infertility of more than 5 years’ duration whose hysteroscopic findings were essentially normal achieved a pregnancy after the procedure, one in the same cycle and two within three cycles of the hysteroscopy. While these pregnancies may be circumstantial, it is tempting to speculate that the uterine distention and the hydrotubation might be related. Hysteroscopy may offer an aid in tubal surgery by allowing the operator to pass catheters transcervically through the interstitial portion of the oviducts into the tubal isthmus or ampulla (Fig. 6). This is useful in tubal reconstructive surgery when reanastomosis is planned. This technique has been used successfully in several patients in this series. The proximal ends of the catheters are then left in a coiled fashion within the uterine
cavity and removed subsequently by hysteroscopy after tubal healing has occurred. More experience with this procedure is necessary before firm conclusions can be drawn as to its utility as an adjunct in tubal reconstructive surgery. While hysteroscopic sterilization by electrocoagulation is an attractive technique since it can be done on an ambulatory basis under local anesthesia, the results have been disappointing. 24 Difficulties in occluding the interstitial portion of the Fallopian tubes have resulted in high failure rates for this procedure. More serious than the failures, however, are recently reported complications associated with electrocoagulation at hysteroscopy.” In a recent collaborative study of the use of hysteroscopic sterilization procedures at 10 centers from the United States, Thailand, West Germany, India, and Singapore, 773 cases were reviewed by Darabi and RichartZ6 The individual series ranged in size from six to 298 cases. Preliminary findings indicate that the over-all failure rate was approximately 36 per cent. although the failure rate in selected series was substantially less. The morbidity statistics indicated that 5.2 per cent of the patients suffered minor complications and 3.2 per cent developed major complications. These included uterine perforations, peritonitis, ectopic pregnancies, and intestinal injuries. In addition, deaths have been reported due to unrecognized major complications. Accordingly, more experience with operative hysteroscopy is necessary before the safety of intrauterine surgery is established. It is possible today to utilize hysteroscopy as an adjunct in the diagnosis of intrauterine pathology. Its applicability as a safe ambulatory procedure makes it an appealing technique for the gynecologist to use in the diagnosis and treatment of common clinical conditions. Its economy and simplicity as well as its positive patient acceptance indicate that it should have a promising future.
REFERENCES 1. Pantaleoni. D. C.: On endoscopic examination of the cavity of the womb, Med. Press. Circ. 8: 26, 1869. 2. Bozzini, P.: Der Lichtleiter, Weimar, 1807, Pearlman, S. J., and Murdock, L. B., Translators, Q. Bull. Northwest. Univ. Med. School 23: 332, 1949. 3. Hays, I.: Instruments of illuminating dark cavities (Note on Fisher, J. D., Boston, and his endoscope), Phil. J. Med. Phys. Sci. 14: 409, 1827. 4. Desormeaux, A. J.: De I’endoscope et de ses applications au diagnostic et au traitment des affections de I’urethre et de la vessie, Paris, 1865, J. B. Baillitre et Fils. 5. Cruise, F. R.: The utility of the endoscope as an aid in the diagnosis and treatment of disease, Dublin Q. J. Med. Sci. 39: 329, 1865. 6. Nitze. M.: Eine neue Beleuchtungs- und Untersuch-
ungs-Methode fiir Harnriihre, Harnblase und Rectum, Wein. Med. Wochenschr. 29: 649, 1879. David, Ch.: L’endoscopie uterine (hysteroscopie). Applications au diagnostic et au traitment des affections intrauterines, Paris, 1908. G. Jacques. Heineberg, A.: Uterine endoscopy; an aid to precision in the diagnosis of intra-uterine disease. A preliminary report, with the presentation of a new uteroscope, Surg. Gynecol. Obstet. 18: 513, 1914. Seymour, H. F.: Endoscopy of the uterus: With a description of a hysteroscope, J. Obstet. Gynecol. Br. Commonw-. 33: 52, 1926. Norment, W. B.: A method of study of the uterine canal, South. Surg. 13: 885, 1947. Parent, B., Toubas, C., and Doerler, B.: L’hysteroscopie decontact, J. Gynecol. Obstet. Biol. Reprod. 3: 511, 1974.
7. 8.
9. 10. 11.
348
Sciarra
and Valle
12. Edstrom, K., and Fernstrdm. I.: The diagnostic possibilities of a modified hysteroscopic technique, Acta Obstet. Gynecol. &and. 49: 327, 1970. 13. Lindemann, H-I.: Transuterine tubal sterilization by CO, hysteroscopy, ir;Sciarra, J. J., Butler, J. C.. and Speidel, J. I.. editors: Hvsteroscooic Sterilization. New York, 1974.
20. Joelsson, 1.: Personal communication, November. 1975. D. UT.: Hysterl>21. Valle, R. F., Sciarra, J. J,, and Freeman, scopic removal of intrauterine devices with missing lilaments, Obstet. Gynecol. In press. D. W.: Hysteroscopy in the 22. Valle. R. F.. and Freeman, localization and removal of intrauterine devices nith “missing strings,” Contraception 11: 161, 1975. 23. Valle. R. F.. and Freeman. D. W.: Hvsteroscopy in tlica management of the “lost” intrauterine device, Advances in Planned Parenthood, Excerpta Medica 10: 164. 1975. research in male and female sterili24. Sciarra. J. J.: Current zation in Schima, M. E., and Lubell, I., editors: New Advances in Sterilization, The Third International Conference on Voluntary Sterilization, Tunis, Tunisia, Frbruary l-4. 1976. New York, 1976, The Association for Voluntary Sterilization, Inc., pp. 189-203. Ch.. and Phaosavasdi. S.: Hysteroscopir 25. Israngkun. sterilization: Complications in 296 cases. in Sciarra, J. .J Droegemueller, W., and Speidel. J. J., editors, Advances in Female Sterilization Techniques, Hagerstown. Maryland, 1976, Harper & Row Publishers, Inc.. pp. 148-152. 26. Darabi. K. F., and Richart, R. M.: Collaborativ-e study on hysteroscopic sterilization prtrcedures: Preliminarv rcport, Obstet. Gynecol. In press. .
I