Opportunities for change and levelling up: a trust wide retrospective analysis of 8 years of laparoscopic and abdominal myomectomy.

Background: Laparoscopic myomectomy is increasingly considered the gold standard uterine preserving procedure and has well documented benefits over the open approach. Barriers that women have in accessing the most appropriate treatment need to be addressed to ensure optimal patient care and outcomes. Objectives: To analyse rates of open and laparoscopic myomectomy at a large NHS trust and identify how many cases could potentially have been performed laparoscopically, and any variation between sites. Materials and Methods: A retrospective review of preoperative imaging reports and a surgical database containing information for all myomectomies performed between 1st January 2015 and 31st December 2022. Main outcome measures: Number of procedures suitable for alternative surgical approach; length of hospital stay; estimated blood loss; cost differences. Results: 846 myomectomies were performed; 656 by laparotomy and 190 by laparoscopy. 194/591 (32.8%) open myomectomies could have been performed laparoscopically and 26/172 (15.1%) laparoscopic myomectomies may have been better performed via an open approach. Length of hospital stay, and estimated blood loss were significantly higher in the open group. Had cases been performed as indicated by pre-operative imaging, the cost differences ranged from -£115,752 to £251,832. Conclusions: There is disparity in access to the gold standard care of laparoscopic myomectomy. Due to multifactorial reasons, even at sites where the rate of laparoscopic myomectomy is high, there is still underutilisation of this approach. It is clear that there is scope for change and "levelling up" of this imbalance. What is new?: Robust pathways and guidelines must be developed, and more laparoscopic surgeons should be trained to optimise care for women with fibroids.

Variation of outcome reporting in studies of interventions for heavy menstrual bleeding: a systematic review.

Background: Heavy menstrual bleeding (HMB) detrimentally effects women. It is important to be able to compare treatments and synthesise data to understand which interventions are most beneficial, however, when there is variation in outcome reporting, this is difficult. Objectives: To identify variation in reported outcomes in clinical studies of interventions for HMB. Materials and Methods: Searches were performed in medical databases and trial registries, using the terms 'heavy menstrual bleeding', menorrhagia*, hypermenorrhoea*, HMB, "heavy period "period", effective*, therapy*, treatment, intervention, manage* and associated MeSH terms. Two authors independently reviewed and selected citations according to pre-defined selection criteria, including both randomised and observational studies. The following data were extracted- study characteristics, methodology and quality, and all reported outcomes. Analysis considered the frequency of reporting. Results: There were 14 individual primary outcomes, however reporting was varied, resulting in 45 specific primary outcomes. There were 165 specific secondary outcomes. The most reported outcomes were menstrual blood loss and adverse events. Conclusions: A core outcome set (COS) would reduce the evident variation in reporting of outcomes in studies of HMB, allowing more complete combination and comparison of study results and preventing reporting bias. What is new?: This in-depth review of past research into heavy menstrual bleeding shows that there is the need for a core outcome set for heavy menstrual bleeding.

An economic evaluation of outpatient versus inpatient polyp treatment for abnormal uterine bleeding.

OBJECTIVES: To undertake a cost-effectiveness analysis of outpatient uterine polypectomy compared with standard inpatient treatment under general anaesthesia. DESIGN: Economic evaluation carried out alongside the multi-centre, pragmatic, non-inferiority, randomised controlled Outpatient Polyp Treatment (OPT) trial. The UK National Health Service (NHS) perspective was used in the estimation of costs and the interpretation of results. SETTING: Thirty-one secondary care UK NHS hospitals between April 2008 and July 2011. PARTICIPANTS: Five hundred and seven women with abnormal uterine bleeding and hysteroscopically diagnosed endometrial polyps. INTERVENTIONS: Outpatient uterine polypectomy versus standard inpatient treatment. Clinicians were free to choose the technique for polypectomy within the allocated setting. MAIN OUTCOME MEASURES: Patient-reported effectiveness of the procedure determined by the women's self-assessment of bleeding at 6 months, and QALY gains at 6 and 12 months. RESULTS: Inpatient treatment was slightly more effective but more expensive than outpatient treatment, resulting in relatively high incremental cost-effectiveness ratios. Intention-to-treat analysis of the base case at 6 months revealed that it cost an additional £9421 per successfully treated patient in the inpatient group and £ 1,099,167 per additional QALY gained, when compared with outpatient treatment. At 12 months, these costs were £22,293 per additional effectively treated patient and £445,867 per additional QALY gained, respectively. CONCLUSIONS: Outpatient treatment of uterine polyps associated with abnormal uterine bleeding appears to be more cost-effective than inpatient treatment at willingness-to-pay thresholds acceptable to the NHS. TWEETABLE ABSTRACT: HTA-funded OPT trial concluded that outpatient uterine polypectomy is cost-effective compared with inpatient polypectomy.

Does cervical preparation before outpatient hysteroscopy reduce women's pain experience? A systematic review.

BACKGROUND: Studies examining the use of pharmaceutical (prostaglandins, antiprogestogens) and mechanical (osmotic dilators) dilatation of the cervix before hysteroscopy under general anaesthesia have produced conflicting results regarding their effect on cervical dilatation and trauma during the procedure. OBJECTIVE: To compare the effect on pain and need for cervical dilatation of various methods of cervical preparation before outpatient hysteroscopy. SEARCH STRATEGY: MEDLINE, EMBASE and CINAHL were searched using a combination of the keywords 'hysteroscopy', 'vaginoscopy', 'cervical ripening', 'laminaria', 'progest*', 'prostaglandin', 'oestrogen''cervical preparation' and their associated Medical Subject Headings The Cochrane Library was searched using the keywords 'hysteroscopy' and 'cervical'. There were no limits or filters placed on the searches. SELECTION CRITERIA: Randomised controlled trials that examined women undergoing outpatient hysteroscopy, where the intervention was the use of cervical preparation versus a control or placebo and the outcome was pain assessment. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials. Data were extracted on pain, the effect on dilatation, adverse effects, trauma and feasibility. Data regarding pain and cervical dilatation were unsuitable for meta-analysis. Meta-analyses were performed for adverse effects and feasibility using the random effects models to calculate the Peto odds ratio. RESULTS: From 585 abstracts, six studies were selected for inclusion in the systematic review. The results suggest that there may be a benefit of using prostaglandins for postmenopausal women; however, there is no high-quality evidence that giving misoprostol before outpatient hysteroscopy reduces the pain experienced by women of reproductive age. There is some evidence that prostaglandins reduce the force and requirement for dilatation of the cervix beyond 5 mm. AUTHOR'S CONCLUSIONS: There is no evidence to recommend the routine administration of mifepristone or misoprostol to women before outpatient hysteroscopy. Cervical priming with vaginal prostaglandins may be considered in postmenopausal women if using hysteroscopic systems >5 mm in diameter.

Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain.

BACKGROUND: Vaginoscopy, also known as the 'no-touch' technique, is an alternative method for performing hysteroscopy without the need for a vaginal speculum to view the cervix or cervical instrumentation to grasp and steady the cervix. OBJECTIVE: To examine the effect of a vaginoscopic approach to outpatient hysteroscopy on the patients' experience of pain, compared with a traditional approach using a vaginal speculum. SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL and the Cochrane Library were searched for relevant articles. No filters or restrictions were placed on the searches. SELECTION CRITERIA: Randomised controlled trials (RCTs) that assess pain when comparing the vaginoscopic technique versus a traditional hysteroscopy in the outpatient setting. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials. Data were abstracted on quality, characteristics and results. Meta-analyses were performed using the random-effects model to calculate the standardised mean difference (SMD). MAIN RESULTS: There were six trials (1321 participants) [corrected]. Data from four of these were meta-analysed, and we found that the use of the vaginoscopic approach to hysteroscopy was less painful than using the traditional technique (SMD -0.44, 95% CI from -0.65 to -0.22, I(2) = 58%). There was no significant difference in the number of failed procedures between groups (P = 0.38). AUTHOR'S CONCLUSIONS: The vaginoscopic approach to outpatient hysteroscopy is successful and significantly reduces the pain experienced by patients during the procedure, compared with traditional techniques using a vaginal speculum. Vaginoscopy should become standard practice for endoscopic instrumentation of the uterine cavity in the outpatient setting.