Histeroscopía quirúrgica: experiencia, resultados y complicaciones según clasificación Clavien-Dindo / Surgical hysteroscopy: experience, results and complications according to Clavien-Dindo classification

OBJETIVO: Describir y analizar la experiencia clínica, resultados y complicaciones según Clavien-Dindo de las histeroscopías quirúrgicas realizadas en pabellón. MÉTODOS: Estudio descriptivo retrospectivo de las histeroscopías quirúrgicas realizadas entre el 1 de enero de 2012 y 1 de enero de 2018 en el Hospital Clínico de la Universidad de Chile. RESULTADOS: Hubo 613 histeroscopías quirúrgicas en el período analizado, de las cuales 593 cumplieron con los requisitos para incluirse en este estudio. Las indicaciones para realizar el procedimiento fueron: pólipo endometrial (56,3%), miomas uterinos (22,1%), sangrado uterino anormal (4,3%) y otras (17,7%). Hubo un 89,2% de concordancia entre el diagnóstico intraoperatorio y el estudio histopatológico. Se pesquisaron 11 hiperplasias endometriales sin atipías, 3 con atipías y 10 neoplasias malignas. Cabe destacar que, del total de pólipos resecados, hubo 8 casos (2,5%) con potencial malignidad (atipías o neoplasia maligna). Según la clasificación Clavien Dindo, hubo 22 complicaciones intraoperatorias (3,7%) grado I o II, cuyo diagnóstico fue realizado en el acto quirúrgico. No hubo complicaciones grado III o más (severas, con reintervención). CONCLUSIÓN: La tasa de éxito, correlación histeroscópica - anatomopatológica final y complicaciones fue similar a lo publicado en la literatura disponible. El diagnóstico intraoperatorio de la lesión y su reparación en el mismo acto quirúrgico, disminuye el riesgo de morbimortalidad de las pacientes, haciéndolo similar al de una paciente sin complicación. Utilizar la clasificación Clavien Dindo para evaluar las complicaciones nos permitirá en adelante, objetivar, mejorar aspectos del procedimiento quirúrgico y plantear estrategias de prevención y manejo de dichos eventos adversos.

OBJECTIVE: To describe and analyze the clinical experience, results and complications according to Clavien-Dindo of surgical hysteroscopies performed in the ward. METHODS: Retrospective descriptive study of surgical hysteroscopies performed between January 1, 2012 and January 1, 2018 at the Hospital Clinico of the University of Chile. RESULTS: There were 613 surgical hysteroscopies in the analyzed period of which 593 fulfilled the requirements to be included in this study. The indications to perform the procedure were: endometrial polyp (56.3%), uterine fibroids (22.1%), abnormal uterine bleeding (4.3%) and others (17.7%). There was an 89.2% agreement between the intraoperative diagnosis and the histopathological study. Eleven endometrial hyperplasias without atypia, 3 with atypia and 10 malignant neoplasms were investigated. It should be noted that, of the total of resected polyps, there were 8 cases (2.5%) with potential malignancy (atypia or malignant neoplasm). According to the Clavien Dindo classification, there were 22 intraoperative complications (3.7%) grade I or II, the diagnosis of which was made during surgery. There were no grade III or more complications (severe, with reoperation). CONCLUSION: The success rate, final hysteroscopic-pathological correlation and complications was similar to that published in the available literature. The intraoperative diagnosis of the lesion and its repair in the same surgical act, reduces the risk of morbidity and mortality of the patients, making it similar to that of a patient without complication. Using the Clavien Dindo classification to assess complications will henceforth allow us to objectify, improve aspects of the surgical procedure and propose strategies for the prevention and management of such adverse events.

Prevalence and intensity of pain during diagnostic hysteroscopy in women attending an infertility clinic: analysis of 489 cases / Prevalência e intensidade da dor na histeroscopia diagnóstica em mulheres atendidas em uma clínica de infertilidade: análise de 489 casos

ABSTRACT Objective To investigate the prevalence and intensity of pain perception during diagnostic hysteroscopy in women and potential related factors. Methods A total of 489 women were investigated at an infertility clinic. Fluid diagnostic hysteroscopy was performed without analgesia or anesthesia by gynecologists with different levels of experience in operative hysteroscopy, using a 2.9mm rigid scope. The Visual Analog Scale was used to score pain intensity after vaginal speculum insertion and after hysteroscopy. Data collected included age, ethnicity, body mass index, history of infertility and endometrial surgery (curettage and/or hysteroscopy), smoking habits, and hysteroscopy diagnosis. Only the state of anxiety was assessed by the State-Trait Anxiety Inventory given to each patient before the procedure. Results Hysteroscopy median (25th to 75th) Visual Analog Scale scored 3.3 (3 to 5), and 41.7% of the women referred Visual Analog Scale score ≥4. Median (25th to 75th) State-Trait Anxiety Inventory score was 42 (38 to 45), and 58.3% of the women referred State-Trait Anxiety Inventory score >40. Hysteroscopy Visual Analog Scale score was significantly correlated to surgeon experience and to vaginal speculum insertion but not to State-Trait Anxiety Inventory score, ethnicity or abnormal hysteroscopic findings. Conclusion Diagnostic hysteroscopy was mostly perceived as a mild discomfort procedure by most women. Nevertheless, in a considerable number of cases, women perceived hysteroscopy as painful. Pain perception was linked to individual pain threshold and surgeon experience, but not to pre-procedural anxiety state levels, ethnicity or abnormal hysteroscopic findings.

RESUMO Objetivo Investigar a prevalência e a intensidade da percepção da dor durante a histeroscopia diagnóstica, bem como os possíveis fatores relacionados. Métodos Foram incluídas 489 mulheres submetidas à propedêutica de infertilidade. A histeroscopia diagnóstica foi realizada sem analgesia ou anestesia, por ginecologistas com níveis de experiência diferentes em histeroscopia, usando histeroscópio rígido de 2,9mm. A Escala Visual Analógica foi utilizada para avaliar a intensidade da dor após a inserção do espéculo vaginal e após a histeroscopia. Os dados coletados incluíram idade, etnia, índice de massa corporal, história de infertilidade e cirurgia endometrial (curetagem e/ou histeroscopia), tabagismo e histeroscopia diagnóstica. Avaliou-se apenas o estado de ansiedade pelo Inventário de Ansiedade Traço-Estado de cada paciente antes do procedimento. Resultados A mediana (25ºa 75º) de histeroscopia pela Escala Visual Analógica foi 3,3 (3 a 5), e 41,7% das mulheres obtiveram pontuação ≥4. A mediana (25ºa 75º) do Inventário de Ansiedade Traço-Estado foi 42 (38 a 45), e 58,3% das mulheres referiram pontuação >40. A pontuação da Escala Visual Analógica da histeroscopia apresentou correlação estatisticamente significante com a experiência do cirurgião e a inserção do espéculo vaginal, mas não a pontuação do Inventário de Ansiedade Traço-Estado, etnia ou achados histeroscópicos anormais. Conclusão A histeroscopia diagnóstica foi percebida pela maioria das mulheres como desconforto leve, mas um número considerável de pacientes classificou o procedimento como doloroso. A percepção da dor esteve ligada ao limiar individual e à experiência do cirurgião, mas não aos níveis de ansiedade pré-procedimento, à etnia e nem aos achados histeroscópicos anormais.

Avaliação da dor em histeroscopia ambulatorial: comparação entre duas técnicas / Pain evaluation in office hysteroscopy: comparison of two techniques

OBJETIVO: comparar a dor referida pelas pacientes submetidas à histeroscopia pela técnica convencional com gás carbônico (CO2) e a vaginohisteroscopia com soro fisiológico (SF 0,9 por cento). MÉTODOS: estudo prospectivo de coorte, realizado em um serviço de histeroscopia ambulatorial. Foram incluídas 117 pacientes com indicação para realizarem o exame, alocadas aleatoriamente em dois grupos. Todas responderam a um questionário epidemiológico e quantificaram a dor esperada antes do exame e sentida após seu término em uma escala verbal de dor de 0 a 10. Para a técnica convencional, foram utilizados espéculo, tração do colo, inserção de ótica de 30º e camisa diagnóstica com diâmetro total 5 mm. A cavidade foi distendida com CO2 sob pressão de 100 mmHg controlada por histeroinsuflador e a biópsia realizada com cureta de Novak. A vaginoscopia foi realizada sem toque, por distensão da vagina com líquido, visualização direta do colo e introdução de ótica com duas camisas de fluxo contínuo com canal acessório de perfil ovalado, totalizando também 5 mm de diâmetro para o conjunto. Foi utilizado SF 0,9 por cento como meio de distensão e a pressão, definida como a necessária para adequada visualização do canal e da cavidade com pressurizador pneumático externo. A biópsia foi realizada de forma dirigida com pinça endoscópica. Foram calculados média e desvio padrão para as variáveis quantitativas e frequência para as qualitativas. O teste t de Student foi utilizado para comparar médias e o teste do qui-quadrado ou exato de Fischer (quando n<5), para análise categórica usando o SPSS 15.0. O estudo foi desenhado para 95 por cento de poder do teste com significância se p<0,05. RESULTADOS: os grupos foram similares quanto a: idade, paridade, cirurgia uterina prévia, estado menopausal e necessidade de biópsia. No grupo vaginoscopia, comparado ao da técnica convencional, houve menor dificuldade técnica (5,1 versus 17,2 por cento, p=0,03), maior taxa de ...

PURPOSE: to compare the pain reported by patients submitted to hysteroscopy by the standard technique with carbon dioxide (CO2) and to vaginal hysteroscopy with physiological saline (0.9 percent NaCl). METHODS: this was a prospective cohort study conducted at an ambulatory hysteroscopy service. A total of 117 patients with indication for the exam were included, being randomly assigned to one of the groups. All patients answered an epidemiological questionnaire and scored the pain expected before the exam and that felt after the end of the procedure on a verbal pain scale from 0 to 10. A speculum, traction of the cervix, insertion of a 30º light source and a diagnostic shirt with a total diameter of 5 mm were used for the standard technique. The cavity was distended with CO2 under a pressure of 100 mmHg controlled with a hysteroflator, and a biopsy was obtained with a Novak curette. Vaginoscopy was performed without a touch by distention of the vagina with fluid, direct visualization of the cervix and introduction of the light source with two continuous-flow shirts, with an accessory channel with an oval profile, the whole set measuring 5 mm in diameter. The medium distention was 0.9 percent NaCl and the pressure used was that considered to be necessary for an adequate visualization of the canal and of the cavity with an external pneumatic pressurizer. The biopsy was obtained in a directed manner using an endoscopic clamp. The mean and standard deviation were calculated for the quantitative variables and the frequency was calculated for the qualitative variables. The Student's t-test was used to compare the means, and the chi-square or exact Fisher test was used (when n<5) for the categorical analysis using the SPSS 15.0 software. The study was designed for a 95 percent test power, with the level of significance set at p<0.05. RESULTS: the groups were similar regarding age, parity, previous uterine surgeries, menopausal status, and the ...

Vaginohisteroscopia en consultorio: histeroscopio de Bettocchi, nueva técnica de diagnóstico y tratamiento ginecológico / Vaginal hysteroscopy in medical center: hysteroscope of Bettocchi, new diagnosis technique and gynecologic treatment

The global trend in surgical procedures is to be as least invasive as possible, causing minor injury to tissues, to reduce the days of hospitalization, to minimize post-operative pain and an early work reintegration. With endoscopy this has achieved and particularly with the hysteroscopy, which is a surgical procedure that allows you to visualize the uterine cavity, to diagnose and resolve the pathologies. The use of the Bettocchi hysteroscope, has revolutionized the gynecological diagnosis and treatment, because it is an ambulatory procedure, without hospitalization nor use of anesthesia. This article aims to describe this technique, its indications and contraindications.

Histerescopía diagnóstica: rendimiento en el estudio de la metrorragia e inocuidad ante un eventual cáncer de endometrio, revisión de la literatura / Diagnostic hysteroscopy in postmenopausal metrorrhagia and safety in endometrial cancer patients: literature review

Objetivo: Evaluar la precisión diagnóstica de la histeroscopia en el estudio del endometrio en pacientes con metrorragia y determinar los riesgos derivados de efectuar el examen en pacientes portadoras de un cáncer de endometrio. Método: Revisión no sistemática de la literatura basada en MEDLINE y rastreo de referencias de artículos relevantes. Resultados: Se identificaron 7 metaanálisis, los cuales incluyen 43.757 pacientes sometidas a diferentes procedimientos para el estudio del endometrio. Se compara el rendimiento de la histeroscopia diagnóstica contra biopsia aspirativa endometrial, ecografía transvaginal e histerosonografía en su correlación con la histología. La histeroscopia resultó ser un examen de muy alta especificidad al igual que la biopsia espirativa, que los hace útiles en el estudio de casos con endometrio anormal seleccionados por ecografía transvaginal. Se examinó las recomendaciones autorizadas, la evidencia a favor y en contra de realizar histeroscopia en pacientes con cáncer de endometrio. Conclusiones: No existe evidencia suficiente para sostener la inocuidad de la histeroscopia diagnóstica en este tipo de pacientes, pero tampoco para afirmar que empeore su pronóstico. Se propone un esquema de estudio de la metrorragia en diferentes situaciones clínicas en base a la evidencia disponible, teniendo en cuenta la sugerencia de evitar en lo posible la histeroscopia en pacientes con riesgo alto de cáncer de endometrio.

Precisión diagnóstica y riesgo de implante secundario en el estudio de carcinoma endometrial por histeroscopía / Diagnostic accuracy and risk of secondary implant in the study of endometrial carcinoma by hysteroscopy

Adenocarcinoma of the endometrium is the most common malignancy of the female genital tract in developed countries. Hysteroscopy has turned into a widely used procedure to improve curettage-biopsy sensibility. Uncertainties have arisen about the hysteroscopic endometrial carcinoma diagnostic sensibility its safety due to the possibility of peritoneal seeding. A MEDLINE and Cochrane Library search was performed. We found that the hysteroscopic diagnosis has low incidence of complications and high diagnostic rate for endometrial carcinoma. There are cytological, case reports and retrospectives studies showing both an increase and also non-increase of seeding risk of cancer cells.

Resección endometrial histeroscópica más inserción de DIU-LNG en el sangrado uterino anormal refractario a tratamiento médico / Hysteroscopic endometrial resection plus LNG-IUD insertion in abnormal uterine bleeding refractory to medical treatment

OBJETIVO: Evaluar los resultados del tratamiento del sangrado uterino anormal (SUA) refractario a tratamiento médico, con resección endometrial histeroscópica asociado a la inserción de un sistema intrauterino de liberación de levonorgestrel. MÉTODO: Estudio prospectivo de 24 pacientes con SUA tratadas con resección endometrial histeroscópica seguida de inserción de un dispositivo intrauterino que libera 20 microgramos diarios de levonorgestrel. RESULTADOS: En 23 de las 24 pacientes tratadas se obtuvo un resultado favorable en término de control del SUA, con un período de seguimiento promedio de 18,3 meses. Una paciente requirió histerectomía por persistencia de dolor pélvico. CONCLUSIÓN: Asociar a la resección endometrial histeroscópica la inserción de un sistema intrauterino de liberación de levonorgestrel mejora los resultados de la cirugía conservadora pudiendo evitar la histerectomía en el 95,9% de las mujeres con SUA de causa benigna.

OBJECTIVE: To evaluate hysteroscopic endometrial resection associated to levonorgestrel intrauterine device insertion as a treatment of abnormal uterine bleeding of benign cause. METHOD: 24 patients with abnormal uterine bleeding, were treated with hysteroscopic endometrial resection followed by the insertion of a intrauterine levonorgestrel device. RESULTS: 23 of 24 patients no report symptoms after 18.3 months follow up. One hysterectomy was performed for persistent chronic pelvic pain. CONCLUSIONS: Endometrial ablations with diathermic loop followed by the insertion of intrauterine levonorgestrel device improve the results of the conservative surgeries, avoiding 95.9% of hysterectomies in patients with abnormal uterine bleeding.

Reproductive outcome following hysteroscopic lysis of intrauterine adhesions: a result of 65 cases at Ramathibodi Hospital.

We reported the reproductive outcome of 65 patients with varying degrees of IUAs who underwent hysteroscopic adhesiolysis between August 1994 and December 1996 at Ramathibodi Hospital. Of the 65 patients treated, 29 had mild adhesions, 26 had moderate adhesions, and 10 had severe adhesions. Adhesions were lysed with hysteroscopic scissors in 25, with biopsy forceps through hysteroscope in 10, with electrosurgery using a monopolar probe in 22 patients, and with resectoscope in 8 patients. The mean duration of the procedure was 15 +/- 2.1 minutes. The mean follow-up was 12 +/- 1.4 months. Of the 44 patients who originally presented with secondary amenorrhea, 40 (90.9%) have normal menses, 4 (9.1%) have hypomenorrhea. Of the 6 patients who had hypomenorrhea, 5 (83.3%) have normal menses. Cyclic abdominal pain disappeared after treatment in all patients. Of the 45 patients with IUAs and infertility, 16 (35.6%) conceived. Two (20%) of the infertile patients with initially severe adhesions conceived. Of the 5 patients with RPL treated, delivered a full term baby and the other delivered a premature baby at 29 weeks of gestation. All 18 patients who delivered, had live births. Adhesion reformation was absent in patients with initially mild and moderate adhesion but occurred in 2 out of 10 (20%) patients with severe adhesions. These two patients initially suffered from secondary amenorrhea but reported hypomenorrhea after surgery. Both of them had tuberculosis of the genital tract. There were no serious complications occurring in all 65 procedures. All 65 patients were discharged a few hours after the operation.

Histeroscopias diagnósticas: experiencia en el Hospital Clínico San Borja Arriarán / Diagnostic hysteroscopy: experience at Hospital Clínico San Borja Arriarán

Presentamos nuestra experiencia con las primeras 350 histeroscopias diagnósticas. Se describe la técnica utilizando CO2 como medio de distensión, su factibilidad de realización sin anestesia ni sedación en un amplio rango de edades y los problemas frecuentes de su ejecución. Los tres principales grupos de indicaciones para examen histeroscópico fueron: sangrado uterino anormal (147 pacientes), hallazgos ecográficos sugerentes de anormalidad endouterina (61 casos) y previo a TRH (43 pacientes), identificándose patología orgánica en el 53,7 por ciento, 50,8 porciento y 11,5 por ciento de los casos, respectivamente. Coincidimos con experiencias anteriores que otorgan gran importancia a este procedimiento