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Hysteroscopy and hysteroscopic surgery
REVIEW
Hysteroscopy and hysteroscopic surgery
a vast increase in the indications and use of the hysteroscope in the present day. Further developments have led to the introduction of smaller endoscopes making hysteroscopy and its procedures now available in an outpatient setting.
Sameer Umranikar
Introduction
Aarti Umranikar
The hysteroscope can be used as a diagnostic tool or used to perform operative procedures within the uterine cavity using larger endoscopes called resectoscopes. Complex surgery is usually performed under a general anaesthetic, however with the advent of finer smaller hysteroscopes, a wide range of simple surgical procedures can now be performed using local anaesthesia. With improved and diverse hysteroscopes the indications for hysteroscopy have also rapidly expanded. Few decades ago dilatation and curettage was one of the commonest gynaecological procedures for abnormal undiagnosed uterine bleeding, which had the potential of missing or delaying the diagnosis of uterine malignancies given the blind nature of the procedure. Better visualization of the uterine cavity with directed endometrial biopsies at hysteroscopies has overcome this and improves the diagnostic accuracy and early diagnosis of endometrial malignancies. However the technique of hysteroscopy has to be learnt and the surgeon performing more complex hysteroscopic procedures should have the knowledge and develop the skills to perform such procedures effectively and safely. This review will discuss the basic principles involved in hysteroscopy and hysteroscopic surgery; and will examine in further detail the current evidence available for the clinical outcomes of different types of hysteroscopic surgery.
Ying Cheong
Abstract Hysteroscopy allows the visualization of the uterine and endocervical cavity under direct vision. Innovations in endoscopic procedures over the last few decades has made hysteroscopy and hysteroscopic surgery more accessible to gynaecology surgeons, and to perform a variety of diagnostic and therapeutic procedures on the uterus. Hysteroscopic surgery should be performed by a skilled surgeon to ensure safe practice and good patient outcomes. This review will discuss the basic principles involved in hysteroscopic surgery and will examine the current evidence for the clinical outcomes of different types of hysteroscopic surgery.
Keywords endometrial ablation; endometrial cancer; heavy menstrual bleeding; hysteroscopy; post-menopausal bleeding; uterine fibroids; uterine polyps
History
Indications Hysteroscopy could be defined as diagnostic or operative depending upon the procedure carried out at the time of the hysteroscopy. Indications for diagnostic hysteroscopy: to investigate menstrual dysfunction (irregular, intermenstrual, post-coital, heavy menstrual bleeding) post-menopausal bleeding vaginal discharge subfertility trace a misplaced intrauterine device Indications for operative hysteroscopy: transcervical resection of endometrium (TCRE) resection of submucosal fibroids/endometrial polyps division of uterine septum adhesiolysis in Ashermann’s syndrome placement of tubal coils (Essure) for sterilization salpingography. Diagnostic and some operative hysteroscopic procedures can be carried out in an office/outpatient setting; certainly with many units now running ‘one stop’ or ‘menstrual disorder clinics’, outpatient hysteroscopic procedures are getting more popular. These procedures are carried out using either flexible or rigid small diameter hysteroscopes. In these clinics the diagnosis, investigations and treatments are carried out during a single consultation.
The first hysteroscope was designed by Desormeaux in 1865, however Pantaleoni performed the first hysteroscopy in 1869 by visualizing the uterine cavity and treating a uterine polyp. Over the next century there have been several innovations and refinements which have led to the introduction of the modern hysteroscope and resectoscope. However before the 1980s there were several factors and technical difficulties which delayed the development of the modern hysteroscope. Distension of the uterine cavity was difficult which resulted in poor views and further traumatization of the endometrium lead to debris which further obscured the surgeon’s views. There were also concerns about gas embolism and carbon dioxide poisoning during uterine insufflation and allergic reactions to distension media such as dextran. However with improved optics from better endoscopes and camera systems, safer distension media and automated insufflating machines hysteroscopic surgery has been revolutionized. This has lead to
Sameer Umranikar MD MRCOG is a Consultant Obstetrician & Gynaecologist at the Princess Anne Hospital, Southampton, UK. Conflicts of interest: none declared. Aarti Umranikar MD MRCOG is a Specialist Registrar in Obstetrics & Gynaecology at the Princess Anne Hospital, Southampton, UK. Conflicts of interest: none declared.
Theatre set-up
Ying Cheong MD MRCOG is a Consultant Gynaecologist & Sub-specialist in Reproductive Medicine at the Princess Anne Hospital, Southampton, UK. Conflicts of interest: none declared.
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The correct theatre set-up is important as it can affect how well the surgery progresses. Normally the surgeon is assisted by a nurse, and
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REVIEW
there should also be another helper, often known as the runner, available to assist with non-sterile equipment such as lighting if necessary. The anaesthetist will be at the head of the operating table whilst the surgeon is positioned between the legs of the patient. The video equipment and the insufflator are placed on the patient’s right, in direct vision of the surgeon so that he/she can see the video screen and the insufflation pressure on the insufflator machine without any obstruction. The sterile trolley with the hysteroscope and the minor surgery tray is placed within the surgeon’s reach, usually behind or to the right side of the surgeon (Figure 1).
Equipment The equipment required to perform a hysteroscopic procedure is the hysteroscope, insufflating media, light source and the camera with the television screen. Hysteroscope The basic parts of a hysteroscope are the cylindrical thin rod which contains the objective lens and is attached to an eye piece on one end. Hysteroscopes available include the rigid, flexible and contact or micro hysteroscope and may be angulated at 0 , 12 or 30 . The 0 hysteroscope gives a straight (unangulated) view. However, the angulated hysteroscope is additionally useful for visualization of structures beyond the field of vision of the standard 0 hysteroscope.
Figure 2 Rigid hysteroscopes 4 mm and 2 mm with rod lens, inner and outer sheaths.
introduced, allowing targeted biopsies or removal of small polyps in an office setting. General anaesthetic is often required for procedures requiring larger diameter hysteroscopes. The outer sheath over the inner hysteroscope allows the flow of the insufflating fluid through the uterine cavity. This movement of fluid is important for good visualization of the uterine cavity as it removes any blood or debris. They also have additional channels for passage of operating instruments.
Rigid hysteroscopes (Figure 2): the diameter of the hysteroscopes ranges from 3 to 10 mm. Smaller telescopes usually between 3 and 5 mm, can be used like the flexible hysteroscopes, where little cervical dilatation is required making the procedure tolerable and acceptable to patients. Local anaesthetic cervical block (peri/paracervical) may be useful. In a recent 2009 Cochrane Review, the effect of paracervical local anaesthesia for cervical dilatation and uterine intervention showed a small reduction in pain relief with paracervical anaesthesia when compared to placebo treatment with saline or water. Thus, the smaller the hysteroscope, better the patient tolerance for the procedure. Some of the smaller diameter hysteroscopes have a small operating port through which instruments can be
Resectoscopes are operating hysteroscopes (Figure 3), which incorporate instruments within it such as the loop, rollerball or barrel electrode. The usually have a 12 downward angulation which allows the operating loop to be visualized at all times. These scopes are used for resection/ablation procedures within the uterine cavity. Originally designed to be used with monopolar current, newer resectoscopes (Gynecare VersapointÔ, Olympus SurgMasterÔ (Figure 4a and b)) now use bipolar energy in an isotonic fluid
Figure 1 Example of the operating room set-up.
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Figure 3 Resectoscope with trolley set-up.
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cavity a distension medium is required to separate the uterine walls needing intrauterine pressure of around 70e120 mmHg. Types of distension media Carbon dioxide gas: used in outpatient hysteroscopy. CO2 automated insufflating systems keep the pressure within the 100e120 mmHg range and at a flow of 30e60 ml/min, so that the risk of gas embolism and carbon dioxide poisoning is minimal. Carbon dioxide distension medium allows the endometrium to be viewed in the natural state. Blood in the uterine cavity can hamper the vision as carbon dioxide is immiscible with blood. Liquid media: electrolytes (dextrose, saline or Hartman’s) or nonelectrolytes (glycine/sorbitol): hysteroscopic surgery needs a liquid medium for the conductance of electrical energy and provision of better views. Non-electrolyte media are used for procedures involving cutting/coagulation as they do not conduct electricity, whereas electrolyte media are used for diagnostic procedures. However newer generation resectoscopes use bipolar energy, which allows an electrolyte medium to be used for hysteroscopic surgery. Using isonatremic (NaCl) medium has advantages over hyponatraemic solutions (glycine, sorbitol) as it can avoid complications associated with fluid overload mainly electrolyte imbalance leading to cerebral/pulmonary oedema and cardiac arrhythmias.
Operative office hysteroscopy
a Olympus SurgMaster resectoscope; b Olympus SurgMaster generator. (Images provided by courtesy of Olympus)
Office hysteroscopy is performed as an outpatient procedure and has many advantages in improved patient satisfaction and better clinical efficacy. Before the procedure, the patient needs to be counselled and consented by the clinician; furthermore, the presence of a nurse during the procedure will provide reassurance to the patient. In a retrospective review of 1000 cases of outpatient hysteroscopy, the procedure was successful in 96%, cervical dilatation was required in 15% and local anaesthesia was required in 31%; 77% of those who required cervical dilatation received local anaesthetics. The procedure failed in 40 patients (4%) for the following reasons: pain or anxiety (23 patients), cervical stenosis (11), equipment failure (4), extreme uterine retroversion (1) and inadvertent false cavity formation (1). A directed biopsy can be performed as part of the procedure, where lesions that are required to be biopsied can be directly visualized as opposed to the traditional blind endometrial sampling. A number of papers have reported the reliability of such biopsies compared to a blind procedure. In inexperienced hands, the biopsy can occasionally contain insufficient tissue for diagnosis. A ‘grasp’ technique1 has been described where the forceps’ jaws are left open and pushed against the endometrium to be biopsied, so that a large piece of endometrium is attached, and the jaws of the forceps are then closed and the entire hysteroscope removed: this appears to double the volume of tissue obtained compared to the normal ‘punch’ technique. Removal of small polyps is also possible with forceps and scissors, although larger size polyps or myomas require general anaesthesia.
Figure 4
medium to produce the necessary cutting/coagulating effect on the tissue. This is achieved by creation of a vapour pocket or steam bubble which, when comes into contact with the tissue causes cellular rupture similar to cell vapourization. Flexible hysteroscope: these are flexible 3 mm fibreoptic hysteroscopes (Figure 5) which use carbon dioxide gas as an insufflating medium. The telescopes are narrow and do not necessarily require cervical dilatation. They have a 100 field of view with a 100 up/ down angulations. These are useful to use in an office setting.
Distension media The uterine cavity is a narrow space kept in opposition by the anterior and posterior uterine walls. For visualization of the uterine
Hysteroscopic surgery In the early days Nd: YAG laser was used for endometrial ablation however its use was limited due to its prohibitive cost. Its advantages allowed the laser to be used in isotonic fluids and
Figure 5 Flexible hysteroscope Olympus HYF-XP. (Image provided by courtesy of Olympus.)
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destroyed the endometrium to a depth of 5 mm. Vancaille subsequently performed the first hysteroscopic rollerball ablation, but it was only in the 1980s that deCherney described good results with endometrial resection and ablation. With further advancements in the hysteroscopes many other procedures like metroplasty, myomectomy, polypectomy, adhesiolysis and contraception have become common procedures today.
Endometrial resection/ablation Heavy menstrual bleeding (HMB) is a leading cause for patient referral into the hospital form the GPs. In the early 1990s almost 60% of women with HMB underwent hysterectomy (NICE, 2007). However with the development of hysteroscopic surgery many women with HMB are now treated conservatively, thus avoiding the morbidity/mortality associated with hysterectomies. In a 1999 Cochrane Reviews2e6 seven RCTs compared endometrial resection/ablation versus hysterectomy for heavy menstrual bleeding. The duration of surgery, hospital stay and recovery were shorter with endometrial ablation techniques. Minor and major adverse events were significantly more with hysterectomy as compared to endometrial techniques. First-generation endometrial ablation techniques were laser ablation, rollerball ablation and transcervical resection of endometrium, which required direct visualization of the uterine cavity whilst undertaking the surgery. Subsequent developments have led to second-generation endometrial ablative techniques like the impedance-controlled bipolar radiofrequency ablation, fluid filled thermal balloon ablation, microwave endometrial ablation and free fluid thermal endometrial ablation. These techniques were introduced to provide simpler, quicker, safer and more successful procedures. They introduce procedure specific instruments into the uterine cavity with the primary aim of generating heat energy to ablate the endometrial lining. They do not require a resectoscope; however, a diagnostic hysteroscopy should be performed to assess the size, shape of the uterine cavity and rule out any sinister pathology.
Figure 6 Loop resection of submucosal fibroid and endometrium.
is created within the operating electrode and resectoscope. During the process of vapourization, a vapour bubble is created which when comes into contact with the cellular tissues causes cell destruction by vapourization giving the cutting effect needed for endometrial resection. During desiccation the electrode when in contact with the tissue causes dehydration of the cells leading to better haemostasis with charring/carbonization. Comparison of endometrial destruction techniques (Cochrane Review,2e6 2009) This review looked at 21 studies with 3395 pre-menopausal participants and compared different endometrial techniques in the treatment of women with heavy menstrual bleeding with no uterine pathology. Their main outcomes were reduction of heavy menstrual bleeding, operative outcomes, satisfaction with outcomes, improvement in the quality of life, complications and need for further surgery or hysterectomy. Comparison of first-generation ablation techniques In general, TCRE appeared to be as effective as the laser vapourization method of ablation in terms of achieving shortterm (6e12 months) outcomes such amenorrhoea rate and satisfaction rate. Duration of laser surgery was an average of 9 min longer than for TCRE. The odds of equipment failure were greater among women who had laser ablation. TCRE, however appeared more likely to be ‘difficult’, with greater fluid deficit and longer duration of surgery. Similarly, TCRE took longer than rollerball ablation, although there were no significant differences between these two first-generation ablation methods in the proportion of cases requiring either hysterectomy or further surgical intervention after 2- and 5-year follow-ups.
Transcervical resection of the endometrium (TCRE) TCRE aims to resect the endometrium under hysteroscopic guidance using a loop electrode (Figure 6). Due to the size of the resectoscope the cervix needs to be dilated to around Hegar 9 or 10. Glycine is used with monopolar current and it is very crucial to maintain a running balance of the inflow and outflow of the glycine to prevent fluid overload and its consequences. The risk of perforation is highest around the fundal and cornual regions and hence most surgeons rollerball the cornua and fundal region before resecting the endometrium on the anterior and posterior uterine wall. The resectoscope is connected to a 50e100 W unipolar electrosurgical generator. In resecting the endometrium on the anterior, posterior and lateral walls systematically, the surgeon will need to bury the cutting loop electrode 4e6 mm into the endometrium and resects the endomyometrial tissue cephalo-caudally. Resection terminates at the endocervical junction. The resected endometrium is about 3e4 mm thick and should include the basal layer of the endometrium to prevent regeneration. Resectoscopes using bipolar energy act on the tissues by a process of vapourization and desiccation. The electrical circuit
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Comparison between first and second-generation ablative techniques There are several studies comparing first-generation techniques (TCRE, rollerball, and laser) with the second-generation techniques (thermal laser, hydro thermoblator, cryoablation, electrode ablation, microwave ablation, impedance-controlled bipolar radiofrequency ablation) (Figure 7). Analyses of the studies show that there are no significant differences in the rate of amenorrhoea between the two techniques up to 5 years after
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The data available on the effectiveness of progestogens as an endometrial thinning agent are limited and one randomized study showed no effect on endometrial thinning using medroxyprogesterone acetate or norethisterone. Some of the second-generation ablation techniques like the balloon and impedance-controlled endometrial ablation system do not need endometrial preparation.8
Reproductive hysteroscopic surgery Fibroids Fibroids are benign growths from the uterine muscle and are classified according to their location in the uterus (submucosal, intramural and serosal). Hysteroscopically submucosal fibroids are classified by The European Society of Hysteroscopy into type 0: pedunculated or polyp fibroid within the uterine cavity with no intramural extension, type 1: intramural extension of the fibroid of <50%, Type 2: intramural extension of the fibroid of >50%9 (Figure 8aed). The fibroids with the adjacent uterine thickness can be mapped pre-operatively by ultrasound. At hysteroscopy the angle of the fibroid to the adjacent myometrium is a useful to differentiate the types of fibroids. The location and size of the fibroid also have implications during treatment. Fibroids greater than 5 cm and fibroids located at the cornual/fundal/cervical areas are more difficult to treat. Pre-operative treatment with GnRH analogues should be given to reduce the size and vascularity to aid resection of the fibroid however the plane between the fibroid and myometrium can be lost making the resection slightly difficult. The relationship between leiomyomas and infertility remains a subject of debate. Fibroids are thought to affect fertility by affecting sperm migration, ovum transport, endometrial vascular disturbances, inflammation and implantation failure. Location of the fibroid is important when considering hysteroscopic treatment. Resection of submucosal fibroids is effective and improves fertility outcomes as compared to intramural or subserosal fibroids. Conception rates of 55% and live birth rates of 80% can be achieved after hysteroscopic myomectomy which are comparable to open myomectomy by laparotomy.10 Hysteroscopic resection of fibroids is sometimes divided into one- or two-step surgery; the latter is usually required if resection is deemed incomplete in the first operation, generally due to the larger size of the fibroid. Removal of fibroids of more than 2 cm improves the pregnancy and live birth rates. In one study the pregnancy rate after the removal of myomas 4.5 cm in size was 57%, while it was 23% for myomas of 5 cm or more.11 The advantages of hysteroscopic myomectomy are avoidance of a laparotomy with its associated risks and adhesion formation, however surgeons undertaking these procedures should be adequately skilled.
Figure 7 Result of treatment of endometrium following second-generation endometrial ablation technique (impedance-controlled radiofrequency ablation).
surgery. However, the satisfaction rates were better for secondgeneration techniques at 2 years after the surgery. First-generation techniques took longer; however the chance of equipment failure was more with second-generation techniques. Complications like fluid overload, perforation, cervical lacerations and haematometra were more common with first-generation techniques as compared to second-generation techniques. The likelihood of using local anaesthesia was more with a secondgeneration technique. With regard to inability to work and requirement for any additional surgery or hysterectomy there was no difference between the two techniques.
Pre-operative endometrial preparation/thinning before endometrial ablation The success of endometrial ablation depends upon the complete destruction of the endometrium within the uterine cavity. This can be achieved when the endometrium is less than 4 mm, usually found post-menstrually. However not all surgical procedures can be timed with the menstrual cycle. Hormonal treatments like GnRH analogues, danazol and progesterone are administered pre-operatively to thin the endometrium. The advantages include reduced (1) endometrial thickness, (2) debris during the operation, (3) uterine vascularity, (4) operating time and (5) fluid absorption. There is a significant reduction in the endometrial thickness on ultrasound (1.6 mm versus 3.53 mm) after the use of goserelin (GnRH agonist).7 In a 2003 Cochrane Review2e6 12 studies using pre-operative hormonal treatments were reviewed. Most of the studies looked at first-generation ablative techniques. They found that GnRH agonist used pre-operatively reduced the duration of the surgery, improved the technique of the surgery, reduced dysmenorrhoea and produced a higher rate of amenorrhoea after a year following the endometrial resection/ablation. GnRH analogue also produced greater endometrial atrophy than danazol. Postoperative amenorrhoea was one measure of the operative outcome that was consistently reported by different studies and the results strongly suggested that there was an increased likelihood of amenorrhoea post-operatively if GnRH analogues were used rather than no treatment.
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Hysteroscopic cannulation of fallopian tube Tubal obstruction can be due to chronic salpingitis isthmica nodosa (SIN), intratubal endometriosis, amorphous material (e.g. mucus plugs) or tubal spasms. Proximal tubal blockage could be amenable to hysteroscopic cannulation. The fallopian tubes can also be cannulated via radiologically assisted selective salpingography or under ultrasound guidance, but the hysteroscopic method is the only method where direct visualization of
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Type 2 Submucous, with intramural portion greater than 50% Type 0 Pedunculated, without intramural extensions
Type 1 Sessile, with intramural portion less than 50%
a
b
c
d
a Classification of types of submucous fibroids; b and c showing Type 1 submucosal fibroids; d showing Type 2 submucosal fibroid. Figure 8
the ostia is possible. The procedure is normally performed with a flexible guidewire within a cannula inserted via the operating channel of an operating hysteroscope and the movement of the cannula through the tube is monitored via laparoscopy. Once the tube is cannulated, the guidewire is removed and a selective salpingography performed, and the spill of dye observed via laparoscopy. There are not many studies examining the reproductive outcome of these procedures, however one study described a 75% success in cannulation rate and a conception rate of 40% with a 3% ectopic pregnancy rate.12
important. Procedures with the highest complications occur during adhesiolysis/resection of a uterine septum (4.48%), myomectomy (0.75%), endometrial resection (0.81%) whereas diagnostic hysteroscopy and polypectomy (0.38%) have a lower complication rate. The incidence of uterine perforation varies according to the type of procedure being undertaken and is quoted from 0.76% to 1%.13 Factors which increase the risk of uterine perforation are nulliparity, menopause, GnRH agonist use, previous cone biopsy, markedly retroverted or anteverted uterus and undue force. When the cervix is stenotic, complications including a cervical tear, the creation of a false cervical passage and uterine perforation can occur. Almost half of the complications are related to cervical entry; therefore, caution and perhaps the use of pre-operative cervical ripening agents like misoprostol may reduce this problem.14 Perforation should be suspected if the visibility is lost and there is difficulty distending the uterus. The procedure should be abandoned if a perforation is suspected, and the patient is given antibiotics and observed for 24 h in hospital. If any other pelvic organ injury (e.g. bowel) is suspected, laparoscopy is needed, particularly when the injury occurs during active surgery involving the application of energy sources such as electro-surgery. Complications related to the distension media are important. CO2 embolism can occur during office hysteroscopy, however CO2 is rapidly absorbed and cleared by the body with minimal effects.
Other conditions Many conditions such as Asherman’s syndrome and uterine anomalies can also be operated on hysteroscopically. However, these are specialized areas which are beyond the scope of this review.
Complications No surgeon is immune to complications during surgery, however with experience, familiarity and knowledge of the surgical procedure, complications rates should be minimized. Complications can occur even with well trained hysteroscopic surgeons. At hysteroscopy complications can occur during and after the procedure, however the type of procedure being carried out is
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REFERENCES 1 Bettocchi S, Nappi L, Ceci O. Advanced operative office hysteroscopy. State of the art atlas of endoscopic surgery in infertility and gynaecology. New York: McGraw Hill Medical, 2004: 465e77. 2 Lethaby A, Shepperd S, Farquhar C, Cooke I. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Rev 1999. 3 Lethaby A, Hickey M, Garry R, Penninx J. Endometrial resection/ablation techniques for heavy menstrual bleeding. Cochrane Rev 2009. 4 Lethaby A, Hickey M, Garry R. Endometrial destruction techniques for heavy menstrual bleeding. Cochrane Rev 2005. 5 Sowter MC, Lethaby A, Singla AA. Pre-operative endometrial thinning agents before endometrial destruction for heavy menstrual bleeding. Cochrane Rev 2003. 6 Tangsiriwatthana T, Sangkomkamhang US, Lumbiganon P, Laopaiboon M. Paracervical local anaesthesia for cervical dilatation and uterine intervention. Cochrane Rev 2009. 7 Donnez J, Vilos G, Gannon MJ, Stampe-Sorensen S, Klinte I, Miller RM. Goserelin Acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: a large randomized, double-blind study. Fertil Steril 1997; 68: 29e36. 8 Cooper J, Brill A, Fulop T. Is endometrial pretreatment necessary in NovaSure 3-D endometrial ablation? Gynaecol Endosc 2002; 10: 179e82. 9 Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol 1993; 82: 736e40. 10 Bajekal N, Li TC. Fibroids, infertility and pregnancy wastage. Hum Reprod Update 2000; 6: 614e20. 11 Fernandez H, Sefrioui O, Virelizier C, et al. Hysteroscopic resection of submucosal myomas in patients with infertility. Hum Reprod 2001; 16: 1489e92. 12 Trivedi P, Padhye A, Agarwal R. Hysteroscopic tubal cannulation, our experience. J Obstet Gynecol Ind 2000; 51: 114e6. 13 Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000; 96: 266e70. 14 Thomas JA, Leyland N, Durand N, Windrim RC. The use of oral misoprostol as a cervical ripening agent in operative hysteroscopy: a double-blind, placebo-controlled trial. Am J Obstet Gynecol 2002; 186: 876e9.
Hypotonic electrolyte-free solutions like glycine and sorbitol can cause hyponatraemic hypervolaemia. Overload of the body’s compensatory mechanism can result in an increase in free water in the brain, hyponatraemia and dilutional hypo-osmolality, resulting in cerebral oedema leading to mental agitation, apprehension, confusion, weakness, nausea, vomiting, visual disturbances, blindness and headache. If left untreated and unrecognized, bradycardia and hypertension can develop, rapidly followed by pulmonary oedema, cardiovascular collapse and death. Recognition and prompt treatment by a critical care specialist may prevent permanent neurological sequelae, death and litigation. A continuous running balance between the inflow and outflow should be maintained during the surgery. If 500e1000 ml (less if the patient is medically compromised) is absorbed, the following must be undertaken: (1) suspend the procedure until fluid status is ascertained, (2) insert a Foley catheter, if not already in place; (3) consider sending serum for immediate measurement of electrolytes; and (4) consider rapid conclusion of the operative procedure as appropriate, as once fluid absorption starts it can progress rapidly. If >1500 ml is absorbed or serum sodium concentration is <125 mmol/l, the procedure must be terminated as rapidly as is reasonable. Patients with a serum sodium level <120 mmol/l must be considered for treatment in a critical care setting. Late complications include post-operative haemorrhage usually secondary to a haematoma formation, thermal damage to bowel and infection (0.2e1%). Team work and training One of the most important pre-requisites for performing successful hysteroscopic surgery and indeed any form of endoscopic surgery is to have a good team that not only understands the intrinsic function of all the equipment but also works well together. Training is essential for the surgeons, nurses and all theatre staff involved in the day to day running of the theatre. Currently, there are many such training courses officially endorsed by the Royal College of Obstetricians and Gynaecologists (RCOG) in the UK. Surgeons undertaking hysteroscopic surgery in the UK need to undertake and complete the Advanced Training Skills Module in hysteroscopic surgery under the guidance of the RCOG. Obviously, with the new medical training structure introduced with the Modernizing Medical Careers programme (MMC), further modification of training for such specialized areas is anticipated. Comprehensive training now or in the future is an absolute necessity prior to performing any hysteroscopic surgery.
Practice points C
C
Conclusion With the advent of hysteroscopic surgery, gynaecologists are now able to treat a multitude of benign gynaecological conditions via this minimally invasive technique rather than open surgery. This has no doubt improved patients’ treatment outcome and satisfaction. However, more research is needed in this rapidly progressing field, especially in the evaluation of the longer-term outcomes of many of these new operative techniques. With the re-organization of junior doctors’ training structure and their working pattern in line with the European Working Time Directive, there is also a need to establish the most efficient training structure for our future surgeons. A
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C
C
C
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Pre-operative GnRh analogues is effective in thinning the endometrial lining before endometrial resection Second-generation ablative techniques have better patient satisfaction rates and are quicker to perform than firstgeneration techniques, however amenorrhoea rates are similar in both techniques at 5 years Electrolyte-free media like glycine can be used with monopolar energy current and the surgery should be suspended if the fluid balance shows a deficit of 500e1000 ml Newer resectoscopes use bipolar energy with isonatremic fluid, however fluid overload can still occur if a fluid balance is not maintained Resection of submucosal fibroids improves menorrhoeagia and enhances fertility rates
Ó 2010 Elsevier Ltd. All rights reserved.
Hysteroscopy and hysteroscopic surgery
a vast increase in the indications and use of the hysteroscope in the present day. Further developments have led to the introduction of smaller endoscopes making hysteroscopy and its procedures now available in an outpatient setting.
Sameer Umranikar
Introduction
Aarti Umranikar
The hysteroscope can be used as a diagnostic tool or used to perform operative procedures within the uterine cavity using larger endoscopes called resectoscopes. Complex surgery is usually performed under a general anaesthetic, however with the advent of finer smaller hysteroscopes, a wide range of simple surgical procedures can now be performed using local anaesthesia. With improved and diverse hysteroscopes the indications for hysteroscopy have also rapidly expanded. Few decades ago dilatation and curettage was one of the commonest gynaecological procedures for abnormal undiagnosed uterine bleeding, which had the potential of missing or delaying the diagnosis of uterine malignancies given the blind nature of the procedure. Better visualization of the uterine cavity with directed endometrial biopsies at hysteroscopies has overcome this and improves the diagnostic accuracy and early diagnosis of endometrial malignancies. However the technique of hysteroscopy has to be learnt and the surgeon performing more complex hysteroscopic procedures should have the knowledge and develop the skills to perform such procedures effectively and safely. This review will discuss the basic principles involved in hysteroscopy and hysteroscopic surgery; and will examine in further detail the current evidence available for the clinical outcomes of different types of hysteroscopic surgery.
Ying Cheong
Abstract Hysteroscopy allows the visualization of the uterine and endocervical cavity under direct vision. Innovations in endoscopic procedures over the last few decades has made hysteroscopy and hysteroscopic surgery more accessible to gynaecology surgeons, and to perform a variety of diagnostic and therapeutic procedures on the uterus. Hysteroscopic surgery should be performed by a skilled surgeon to ensure safe practice and good patient outcomes. This review will discuss the basic principles involved in hysteroscopic surgery and will examine the current evidence for the clinical outcomes of different types of hysteroscopic surgery.
Keywords endometrial ablation; endometrial cancer; heavy menstrual bleeding; hysteroscopy; post-menopausal bleeding; uterine fibroids; uterine polyps
History
Indications Hysteroscopy could be defined as diagnostic or operative depending upon the procedure carried out at the time of the hysteroscopy. Indications for diagnostic hysteroscopy: to investigate menstrual dysfunction (irregular, intermenstrual, post-coital, heavy menstrual bleeding) post-menopausal bleeding vaginal discharge subfertility trace a misplaced intrauterine device Indications for operative hysteroscopy: transcervical resection of endometrium (TCRE) resection of submucosal fibroids/endometrial polyps division of uterine septum adhesiolysis in Ashermann’s syndrome placement of tubal coils (Essure) for sterilization salpingography. Diagnostic and some operative hysteroscopic procedures can be carried out in an office/outpatient setting; certainly with many units now running ‘one stop’ or ‘menstrual disorder clinics’, outpatient hysteroscopic procedures are getting more popular. These procedures are carried out using either flexible or rigid small diameter hysteroscopes. In these clinics the diagnosis, investigations and treatments are carried out during a single consultation.
The first hysteroscope was designed by Desormeaux in 1865, however Pantaleoni performed the first hysteroscopy in 1869 by visualizing the uterine cavity and treating a uterine polyp. Over the next century there have been several innovations and refinements which have led to the introduction of the modern hysteroscope and resectoscope. However before the 1980s there were several factors and technical difficulties which delayed the development of the modern hysteroscope. Distension of the uterine cavity was difficult which resulted in poor views and further traumatization of the endometrium lead to debris which further obscured the surgeon’s views. There were also concerns about gas embolism and carbon dioxide poisoning during uterine insufflation and allergic reactions to distension media such as dextran. However with improved optics from better endoscopes and camera systems, safer distension media and automated insufflating machines hysteroscopic surgery has been revolutionized. This has lead to
Sameer Umranikar MD MRCOG is a Consultant Obstetrician & Gynaecologist at the Princess Anne Hospital, Southampton, UK. Conflicts of interest: none declared. Aarti Umranikar MD MRCOG is a Specialist Registrar in Obstetrics & Gynaecology at the Princess Anne Hospital, Southampton, UK. Conflicts of interest: none declared.
Theatre set-up
Ying Cheong MD MRCOG is a Consultant Gynaecologist & Sub-specialist in Reproductive Medicine at the Princess Anne Hospital, Southampton, UK. Conflicts of interest: none declared.
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The correct theatre set-up is important as it can affect how well the surgery progresses. Normally the surgeon is assisted by a nurse, and
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there should also be another helper, often known as the runner, available to assist with non-sterile equipment such as lighting if necessary. The anaesthetist will be at the head of the operating table whilst the surgeon is positioned between the legs of the patient. The video equipment and the insufflator are placed on the patient’s right, in direct vision of the surgeon so that he/she can see the video screen and the insufflation pressure on the insufflator machine without any obstruction. The sterile trolley with the hysteroscope and the minor surgery tray is placed within the surgeon’s reach, usually behind or to the right side of the surgeon (Figure 1).
Equipment The equipment required to perform a hysteroscopic procedure is the hysteroscope, insufflating media, light source and the camera with the television screen. Hysteroscope The basic parts of a hysteroscope are the cylindrical thin rod which contains the objective lens and is attached to an eye piece on one end. Hysteroscopes available include the rigid, flexible and contact or micro hysteroscope and may be angulated at 0 , 12 or 30 . The 0 hysteroscope gives a straight (unangulated) view. However, the angulated hysteroscope is additionally useful for visualization of structures beyond the field of vision of the standard 0 hysteroscope.
Figure 2 Rigid hysteroscopes 4 mm and 2 mm with rod lens, inner and outer sheaths.
introduced, allowing targeted biopsies or removal of small polyps in an office setting. General anaesthetic is often required for procedures requiring larger diameter hysteroscopes. The outer sheath over the inner hysteroscope allows the flow of the insufflating fluid through the uterine cavity. This movement of fluid is important for good visualization of the uterine cavity as it removes any blood or debris. They also have additional channels for passage of operating instruments.
Rigid hysteroscopes (Figure 2): the diameter of the hysteroscopes ranges from 3 to 10 mm. Smaller telescopes usually between 3 and 5 mm, can be used like the flexible hysteroscopes, where little cervical dilatation is required making the procedure tolerable and acceptable to patients. Local anaesthetic cervical block (peri/paracervical) may be useful. In a recent 2009 Cochrane Review, the effect of paracervical local anaesthesia for cervical dilatation and uterine intervention showed a small reduction in pain relief with paracervical anaesthesia when compared to placebo treatment with saline or water. Thus, the smaller the hysteroscope, better the patient tolerance for the procedure. Some of the smaller diameter hysteroscopes have a small operating port through which instruments can be
Resectoscopes are operating hysteroscopes (Figure 3), which incorporate instruments within it such as the loop, rollerball or barrel electrode. The usually have a 12 downward angulation which allows the operating loop to be visualized at all times. These scopes are used for resection/ablation procedures within the uterine cavity. Originally designed to be used with monopolar current, newer resectoscopes (Gynecare VersapointÔ, Olympus SurgMasterÔ (Figure 4a and b)) now use bipolar energy in an isotonic fluid
Figure 1 Example of the operating room set-up.
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Figure 3 Resectoscope with trolley set-up.
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cavity a distension medium is required to separate the uterine walls needing intrauterine pressure of around 70e120 mmHg. Types of distension media Carbon dioxide gas: used in outpatient hysteroscopy. CO2 automated insufflating systems keep the pressure within the 100e120 mmHg range and at a flow of 30e60 ml/min, so that the risk of gas embolism and carbon dioxide poisoning is minimal. Carbon dioxide distension medium allows the endometrium to be viewed in the natural state. Blood in the uterine cavity can hamper the vision as carbon dioxide is immiscible with blood. Liquid media: electrolytes (dextrose, saline or Hartman’s) or nonelectrolytes (glycine/sorbitol): hysteroscopic surgery needs a liquid medium for the conductance of electrical energy and provision of better views. Non-electrolyte media are used for procedures involving cutting/coagulation as they do not conduct electricity, whereas electrolyte media are used for diagnostic procedures. However newer generation resectoscopes use bipolar energy, which allows an electrolyte medium to be used for hysteroscopic surgery. Using isonatremic (NaCl) medium has advantages over hyponatraemic solutions (glycine, sorbitol) as it can avoid complications associated with fluid overload mainly electrolyte imbalance leading to cerebral/pulmonary oedema and cardiac arrhythmias.
Operative office hysteroscopy
a Olympus SurgMaster resectoscope; b Olympus SurgMaster generator. (Images provided by courtesy of Olympus)
Office hysteroscopy is performed as an outpatient procedure and has many advantages in improved patient satisfaction and better clinical efficacy. Before the procedure, the patient needs to be counselled and consented by the clinician; furthermore, the presence of a nurse during the procedure will provide reassurance to the patient. In a retrospective review of 1000 cases of outpatient hysteroscopy, the procedure was successful in 96%, cervical dilatation was required in 15% and local anaesthesia was required in 31%; 77% of those who required cervical dilatation received local anaesthetics. The procedure failed in 40 patients (4%) for the following reasons: pain or anxiety (23 patients), cervical stenosis (11), equipment failure (4), extreme uterine retroversion (1) and inadvertent false cavity formation (1). A directed biopsy can be performed as part of the procedure, where lesions that are required to be biopsied can be directly visualized as opposed to the traditional blind endometrial sampling. A number of papers have reported the reliability of such biopsies compared to a blind procedure. In inexperienced hands, the biopsy can occasionally contain insufficient tissue for diagnosis. A ‘grasp’ technique1 has been described where the forceps’ jaws are left open and pushed against the endometrium to be biopsied, so that a large piece of endometrium is attached, and the jaws of the forceps are then closed and the entire hysteroscope removed: this appears to double the volume of tissue obtained compared to the normal ‘punch’ technique. Removal of small polyps is also possible with forceps and scissors, although larger size polyps or myomas require general anaesthesia.
Figure 4
medium to produce the necessary cutting/coagulating effect on the tissue. This is achieved by creation of a vapour pocket or steam bubble which, when comes into contact with the tissue causes cellular rupture similar to cell vapourization. Flexible hysteroscope: these are flexible 3 mm fibreoptic hysteroscopes (Figure 5) which use carbon dioxide gas as an insufflating medium. The telescopes are narrow and do not necessarily require cervical dilatation. They have a 100 field of view with a 100 up/ down angulations. These are useful to use in an office setting.
Distension media The uterine cavity is a narrow space kept in opposition by the anterior and posterior uterine walls. For visualization of the uterine
Hysteroscopic surgery In the early days Nd: YAG laser was used for endometrial ablation however its use was limited due to its prohibitive cost. Its advantages allowed the laser to be used in isotonic fluids and
Figure 5 Flexible hysteroscope Olympus HYF-XP. (Image provided by courtesy of Olympus.)
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destroyed the endometrium to a depth of 5 mm. Vancaille subsequently performed the first hysteroscopic rollerball ablation, but it was only in the 1980s that deCherney described good results with endometrial resection and ablation. With further advancements in the hysteroscopes many other procedures like metroplasty, myomectomy, polypectomy, adhesiolysis and contraception have become common procedures today.
Endometrial resection/ablation Heavy menstrual bleeding (HMB) is a leading cause for patient referral into the hospital form the GPs. In the early 1990s almost 60% of women with HMB underwent hysterectomy (NICE, 2007). However with the development of hysteroscopic surgery many women with HMB are now treated conservatively, thus avoiding the morbidity/mortality associated with hysterectomies. In a 1999 Cochrane Reviews2e6 seven RCTs compared endometrial resection/ablation versus hysterectomy for heavy menstrual bleeding. The duration of surgery, hospital stay and recovery were shorter with endometrial ablation techniques. Minor and major adverse events were significantly more with hysterectomy as compared to endometrial techniques. First-generation endometrial ablation techniques were laser ablation, rollerball ablation and transcervical resection of endometrium, which required direct visualization of the uterine cavity whilst undertaking the surgery. Subsequent developments have led to second-generation endometrial ablative techniques like the impedance-controlled bipolar radiofrequency ablation, fluid filled thermal balloon ablation, microwave endometrial ablation and free fluid thermal endometrial ablation. These techniques were introduced to provide simpler, quicker, safer and more successful procedures. They introduce procedure specific instruments into the uterine cavity with the primary aim of generating heat energy to ablate the endometrial lining. They do not require a resectoscope; however, a diagnostic hysteroscopy should be performed to assess the size, shape of the uterine cavity and rule out any sinister pathology.
Figure 6 Loop resection of submucosal fibroid and endometrium.
is created within the operating electrode and resectoscope. During the process of vapourization, a vapour bubble is created which when comes into contact with the cellular tissues causes cell destruction by vapourization giving the cutting effect needed for endometrial resection. During desiccation the electrode when in contact with the tissue causes dehydration of the cells leading to better haemostasis with charring/carbonization. Comparison of endometrial destruction techniques (Cochrane Review,2e6 2009) This review looked at 21 studies with 3395 pre-menopausal participants and compared different endometrial techniques in the treatment of women with heavy menstrual bleeding with no uterine pathology. Their main outcomes were reduction of heavy menstrual bleeding, operative outcomes, satisfaction with outcomes, improvement in the quality of life, complications and need for further surgery or hysterectomy. Comparison of first-generation ablation techniques In general, TCRE appeared to be as effective as the laser vapourization method of ablation in terms of achieving shortterm (6e12 months) outcomes such amenorrhoea rate and satisfaction rate. Duration of laser surgery was an average of 9 min longer than for TCRE. The odds of equipment failure were greater among women who had laser ablation. TCRE, however appeared more likely to be ‘difficult’, with greater fluid deficit and longer duration of surgery. Similarly, TCRE took longer than rollerball ablation, although there were no significant differences between these two first-generation ablation methods in the proportion of cases requiring either hysterectomy or further surgical intervention after 2- and 5-year follow-ups.
Transcervical resection of the endometrium (TCRE) TCRE aims to resect the endometrium under hysteroscopic guidance using a loop electrode (Figure 6). Due to the size of the resectoscope the cervix needs to be dilated to around Hegar 9 or 10. Glycine is used with monopolar current and it is very crucial to maintain a running balance of the inflow and outflow of the glycine to prevent fluid overload and its consequences. The risk of perforation is highest around the fundal and cornual regions and hence most surgeons rollerball the cornua and fundal region before resecting the endometrium on the anterior and posterior uterine wall. The resectoscope is connected to a 50e100 W unipolar electrosurgical generator. In resecting the endometrium on the anterior, posterior and lateral walls systematically, the surgeon will need to bury the cutting loop electrode 4e6 mm into the endometrium and resects the endomyometrial tissue cephalo-caudally. Resection terminates at the endocervical junction. The resected endometrium is about 3e4 mm thick and should include the basal layer of the endometrium to prevent regeneration. Resectoscopes using bipolar energy act on the tissues by a process of vapourization and desiccation. The electrical circuit
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Comparison between first and second-generation ablative techniques There are several studies comparing first-generation techniques (TCRE, rollerball, and laser) with the second-generation techniques (thermal laser, hydro thermoblator, cryoablation, electrode ablation, microwave ablation, impedance-controlled bipolar radiofrequency ablation) (Figure 7). Analyses of the studies show that there are no significant differences in the rate of amenorrhoea between the two techniques up to 5 years after
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The data available on the effectiveness of progestogens as an endometrial thinning agent are limited and one randomized study showed no effect on endometrial thinning using medroxyprogesterone acetate or norethisterone. Some of the second-generation ablation techniques like the balloon and impedance-controlled endometrial ablation system do not need endometrial preparation.8
Reproductive hysteroscopic surgery Fibroids Fibroids are benign growths from the uterine muscle and are classified according to their location in the uterus (submucosal, intramural and serosal). Hysteroscopically submucosal fibroids are classified by The European Society of Hysteroscopy into type 0: pedunculated or polyp fibroid within the uterine cavity with no intramural extension, type 1: intramural extension of the fibroid of <50%, Type 2: intramural extension of the fibroid of >50%9 (Figure 8aed). The fibroids with the adjacent uterine thickness can be mapped pre-operatively by ultrasound. At hysteroscopy the angle of the fibroid to the adjacent myometrium is a useful to differentiate the types of fibroids. The location and size of the fibroid also have implications during treatment. Fibroids greater than 5 cm and fibroids located at the cornual/fundal/cervical areas are more difficult to treat. Pre-operative treatment with GnRH analogues should be given to reduce the size and vascularity to aid resection of the fibroid however the plane between the fibroid and myometrium can be lost making the resection slightly difficult. The relationship between leiomyomas and infertility remains a subject of debate. Fibroids are thought to affect fertility by affecting sperm migration, ovum transport, endometrial vascular disturbances, inflammation and implantation failure. Location of the fibroid is important when considering hysteroscopic treatment. Resection of submucosal fibroids is effective and improves fertility outcomes as compared to intramural or subserosal fibroids. Conception rates of 55% and live birth rates of 80% can be achieved after hysteroscopic myomectomy which are comparable to open myomectomy by laparotomy.10 Hysteroscopic resection of fibroids is sometimes divided into one- or two-step surgery; the latter is usually required if resection is deemed incomplete in the first operation, generally due to the larger size of the fibroid. Removal of fibroids of more than 2 cm improves the pregnancy and live birth rates. In one study the pregnancy rate after the removal of myomas 4.5 cm in size was 57%, while it was 23% for myomas of 5 cm or more.11 The advantages of hysteroscopic myomectomy are avoidance of a laparotomy with its associated risks and adhesion formation, however surgeons undertaking these procedures should be adequately skilled.
Figure 7 Result of treatment of endometrium following second-generation endometrial ablation technique (impedance-controlled radiofrequency ablation).
surgery. However, the satisfaction rates were better for secondgeneration techniques at 2 years after the surgery. First-generation techniques took longer; however the chance of equipment failure was more with second-generation techniques. Complications like fluid overload, perforation, cervical lacerations and haematometra were more common with first-generation techniques as compared to second-generation techniques. The likelihood of using local anaesthesia was more with a secondgeneration technique. With regard to inability to work and requirement for any additional surgery or hysterectomy there was no difference between the two techniques.
Pre-operative endometrial preparation/thinning before endometrial ablation The success of endometrial ablation depends upon the complete destruction of the endometrium within the uterine cavity. This can be achieved when the endometrium is less than 4 mm, usually found post-menstrually. However not all surgical procedures can be timed with the menstrual cycle. Hormonal treatments like GnRH analogues, danazol and progesterone are administered pre-operatively to thin the endometrium. The advantages include reduced (1) endometrial thickness, (2) debris during the operation, (3) uterine vascularity, (4) operating time and (5) fluid absorption. There is a significant reduction in the endometrial thickness on ultrasound (1.6 mm versus 3.53 mm) after the use of goserelin (GnRH agonist).7 In a 2003 Cochrane Review2e6 12 studies using pre-operative hormonal treatments were reviewed. Most of the studies looked at first-generation ablative techniques. They found that GnRH agonist used pre-operatively reduced the duration of the surgery, improved the technique of the surgery, reduced dysmenorrhoea and produced a higher rate of amenorrhoea after a year following the endometrial resection/ablation. GnRH analogue also produced greater endometrial atrophy than danazol. Postoperative amenorrhoea was one measure of the operative outcome that was consistently reported by different studies and the results strongly suggested that there was an increased likelihood of amenorrhoea post-operatively if GnRH analogues were used rather than no treatment.
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Hysteroscopic cannulation of fallopian tube Tubal obstruction can be due to chronic salpingitis isthmica nodosa (SIN), intratubal endometriosis, amorphous material (e.g. mucus plugs) or tubal spasms. Proximal tubal blockage could be amenable to hysteroscopic cannulation. The fallopian tubes can also be cannulated via radiologically assisted selective salpingography or under ultrasound guidance, but the hysteroscopic method is the only method where direct visualization of
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Type 2 Submucous, with intramural portion greater than 50% Type 0 Pedunculated, without intramural extensions
Type 1 Sessile, with intramural portion less than 50%
a
b
c
d
a Classification of types of submucous fibroids; b and c showing Type 1 submucosal fibroids; d showing Type 2 submucosal fibroid. Figure 8
the ostia is possible. The procedure is normally performed with a flexible guidewire within a cannula inserted via the operating channel of an operating hysteroscope and the movement of the cannula through the tube is monitored via laparoscopy. Once the tube is cannulated, the guidewire is removed and a selective salpingography performed, and the spill of dye observed via laparoscopy. There are not many studies examining the reproductive outcome of these procedures, however one study described a 75% success in cannulation rate and a conception rate of 40% with a 3% ectopic pregnancy rate.12
important. Procedures with the highest complications occur during adhesiolysis/resection of a uterine septum (4.48%), myomectomy (0.75%), endometrial resection (0.81%) whereas diagnostic hysteroscopy and polypectomy (0.38%) have a lower complication rate. The incidence of uterine perforation varies according to the type of procedure being undertaken and is quoted from 0.76% to 1%.13 Factors which increase the risk of uterine perforation are nulliparity, menopause, GnRH agonist use, previous cone biopsy, markedly retroverted or anteverted uterus and undue force. When the cervix is stenotic, complications including a cervical tear, the creation of a false cervical passage and uterine perforation can occur. Almost half of the complications are related to cervical entry; therefore, caution and perhaps the use of pre-operative cervical ripening agents like misoprostol may reduce this problem.14 Perforation should be suspected if the visibility is lost and there is difficulty distending the uterus. The procedure should be abandoned if a perforation is suspected, and the patient is given antibiotics and observed for 24 h in hospital. If any other pelvic organ injury (e.g. bowel) is suspected, laparoscopy is needed, particularly when the injury occurs during active surgery involving the application of energy sources such as electro-surgery. Complications related to the distension media are important. CO2 embolism can occur during office hysteroscopy, however CO2 is rapidly absorbed and cleared by the body with minimal effects.
Other conditions Many conditions such as Asherman’s syndrome and uterine anomalies can also be operated on hysteroscopically. However, these are specialized areas which are beyond the scope of this review.
Complications No surgeon is immune to complications during surgery, however with experience, familiarity and knowledge of the surgical procedure, complications rates should be minimized. Complications can occur even with well trained hysteroscopic surgeons. At hysteroscopy complications can occur during and after the procedure, however the type of procedure being carried out is
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REFERENCES 1 Bettocchi S, Nappi L, Ceci O. Advanced operative office hysteroscopy. State of the art atlas of endoscopic surgery in infertility and gynaecology. New York: McGraw Hill Medical, 2004: 465e77. 2 Lethaby A, Shepperd S, Farquhar C, Cooke I. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Rev 1999. 3 Lethaby A, Hickey M, Garry R, Penninx J. Endometrial resection/ablation techniques for heavy menstrual bleeding. Cochrane Rev 2009. 4 Lethaby A, Hickey M, Garry R. Endometrial destruction techniques for heavy menstrual bleeding. Cochrane Rev 2005. 5 Sowter MC, Lethaby A, Singla AA. Pre-operative endometrial thinning agents before endometrial destruction for heavy menstrual bleeding. Cochrane Rev 2003. 6 Tangsiriwatthana T, Sangkomkamhang US, Lumbiganon P, Laopaiboon M. Paracervical local anaesthesia for cervical dilatation and uterine intervention. Cochrane Rev 2009. 7 Donnez J, Vilos G, Gannon MJ, Stampe-Sorensen S, Klinte I, Miller RM. Goserelin Acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: a large randomized, double-blind study. Fertil Steril 1997; 68: 29e36. 8 Cooper J, Brill A, Fulop T. Is endometrial pretreatment necessary in NovaSure 3-D endometrial ablation? Gynaecol Endosc 2002; 10: 179e82. 9 Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol 1993; 82: 736e40. 10 Bajekal N, Li TC. Fibroids, infertility and pregnancy wastage. Hum Reprod Update 2000; 6: 614e20. 11 Fernandez H, Sefrioui O, Virelizier C, et al. Hysteroscopic resection of submucosal myomas in patients with infertility. Hum Reprod 2001; 16: 1489e92. 12 Trivedi P, Padhye A, Agarwal R. Hysteroscopic tubal cannulation, our experience. J Obstet Gynecol Ind 2000; 51: 114e6. 13 Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000; 96: 266e70. 14 Thomas JA, Leyland N, Durand N, Windrim RC. The use of oral misoprostol as a cervical ripening agent in operative hysteroscopy: a double-blind, placebo-controlled trial. Am J Obstet Gynecol 2002; 186: 876e9.
Hypotonic electrolyte-free solutions like glycine and sorbitol can cause hyponatraemic hypervolaemia. Overload of the body’s compensatory mechanism can result in an increase in free water in the brain, hyponatraemia and dilutional hypo-osmolality, resulting in cerebral oedema leading to mental agitation, apprehension, confusion, weakness, nausea, vomiting, visual disturbances, blindness and headache. If left untreated and unrecognized, bradycardia and hypertension can develop, rapidly followed by pulmonary oedema, cardiovascular collapse and death. Recognition and prompt treatment by a critical care specialist may prevent permanent neurological sequelae, death and litigation. A continuous running balance between the inflow and outflow should be maintained during the surgery. If 500e1000 ml (less if the patient is medically compromised) is absorbed, the following must be undertaken: (1) suspend the procedure until fluid status is ascertained, (2) insert a Foley catheter, if not already in place; (3) consider sending serum for immediate measurement of electrolytes; and (4) consider rapid conclusion of the operative procedure as appropriate, as once fluid absorption starts it can progress rapidly. If >1500 ml is absorbed or serum sodium concentration is <125 mmol/l, the procedure must be terminated as rapidly as is reasonable. Patients with a serum sodium level <120 mmol/l must be considered for treatment in a critical care setting. Late complications include post-operative haemorrhage usually secondary to a haematoma formation, thermal damage to bowel and infection (0.2e1%). Team work and training One of the most important pre-requisites for performing successful hysteroscopic surgery and indeed any form of endoscopic surgery is to have a good team that not only understands the intrinsic function of all the equipment but also works well together. Training is essential for the surgeons, nurses and all theatre staff involved in the day to day running of the theatre. Currently, there are many such training courses officially endorsed by the Royal College of Obstetricians and Gynaecologists (RCOG) in the UK. Surgeons undertaking hysteroscopic surgery in the UK need to undertake and complete the Advanced Training Skills Module in hysteroscopic surgery under the guidance of the RCOG. Obviously, with the new medical training structure introduced with the Modernizing Medical Careers programme (MMC), further modification of training for such specialized areas is anticipated. Comprehensive training now or in the future is an absolute necessity prior to performing any hysteroscopic surgery.
Practice points C
C
Conclusion With the advent of hysteroscopic surgery, gynaecologists are now able to treat a multitude of benign gynaecological conditions via this minimally invasive technique rather than open surgery. This has no doubt improved patients’ treatment outcome and satisfaction. However, more research is needed in this rapidly progressing field, especially in the evaluation of the longer-term outcomes of many of these new operative techniques. With the re-organization of junior doctors’ training structure and their working pattern in line with the European Working Time Directive, there is also a need to establish the most efficient training structure for our future surgeons. A
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Pre-operative GnRh analogues is effective in thinning the endometrial lining before endometrial resection Second-generation ablative techniques have better patient satisfaction rates and are quicker to perform than firstgeneration techniques, however amenorrhoea rates are similar in both techniques at 5 years Electrolyte-free media like glycine can be used with monopolar energy current and the surgery should be suspended if the fluid balance shows a deficit of 500e1000 ml Newer resectoscopes use bipolar energy with isonatremic fluid, however fluid overload can still occur if a fluid balance is not maintained Resection of submucosal fibroids improves menorrhoeagia and enhances fertility rates
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