Use of local anesthesia for office diagnostic and operative hysteroscopy.

BACKGROUND: There is a variety of potential advantages to performing hysteroscopically-directed procedures on an awake patient in an office procedure room setting that include increased safety, reduced utilization of resources, and improved patient satisfaction. However, the ideal approach to local uterine anesthesia has/have yet to be determined. OBJECTIVE: Identification, categorization, and evaluation of published randomized clinical trials (RCTs) comparing local anesthesia to placebo or no treatment for the performance of hysteroscopy. METHODS: The Cochrane database of systematic reviews, MEDLINE, and ACP Journal Club were queried for related RCTs. In addition, we located a number of additional studies by identifying and reviewing references in selected papers. These were then reviewed for appropriateness and categorized by allocating them to one of the following types of local anesthesia: Intracervical, paracervical, topical intracavitary, topical cervical, and combined approaches. Each were evaluated for patient factors as well as anesthetic location, anesthetic agent, time from application to procedure, instrument features, and the procedures performed. RESULTS: A total of 36 studies were identified of which 19 met the criteria for our review; 6 paracervical, 4 intracervical, 7 topical intracavitary, 2 topical cervical; there was also one systematic review of RCTs. Overall, there was substantial heterogeneity in technique in all groups and only with paracervical anesthesia was there a consistent anesthetic effect demonstrated. Many studies were performed with application to procedure times that were less than the time required for maximal anesthetic effect. There were no studies identified where more than one technique was used. CONCLUSIONS: It appears that paracervical anesthesia is useful but the value of other techniques is difficult to evaluate because of limitations of technique and research design. Future investigation should be designed to evaluate longer application to procedure times, a variety of anesthetic agents, concentrations and volumes, and, given the complex innervation of the uterus, strategies that target more than one site. Pain outcomes should be stratified to identify the impact on various components of the procedure. Published studies have largely been limited to diagnostic hysteroscopy so there is also a need to evaluate a greater variety of hysteroscopic procedures.

The long-term effects of the Holocaust on the reproductive function of female survivors.

STUDY OBJECTIVE: The aim of this study was to evaluate the effect of internment in the German concentration camps during World War II on menstrual function; future fertility; and, ultimately, on gynecologic diseases or future surgery needs. SUBJECTS: Five hundred eighty Hungarian female survivors of concentration camps. INTERVENTION: Menstrual and reproductive histories of the women were obtained and analyzed, comparing histories and events from pre-internment, internment, and post-internment periods of time. MEASUREMENTS AND MAIN RESULTS: The mean age of the survivors at the time of internment was 23.4 +/- 8.0 years (95% CI 22.7-24.1). Amenorrhea occurred in 94.8% of the women during encampment (95% CI 92.7%-96.5%), with 82.4% experiencing cessation of menses immediately after internment (95% CI 76.9%-85.6%). Only 0.6% of women (95% CI 0.12%-1.63%) menstruated longer than 4 months after internment. After liberation, all but 8.9% of the women resumed menstruation within the first year (95% CI 88.4%-93.3%). Fecundity subsequent to liberation was not significantly affected by the imprisonment nor was there a significant increase in spontaneous abortion, ectopic pregnancies, stillbirths, or other pregnancy complications. Additionally, there was no evidence of impact on the subsequent frequency of gynecologic diseases or surgical procedures. CONCLUSIONS: Imprisonment in German concentration camps during the Holocaust resulted in enormous emotional and psychological changes in the survivors. In addition, this study reveals abrupt changes in short-term menstrual function but little long-term physical damage to reproductive function.

In the management of abnormal uterine bleeding, is office hysteroscopy preferable to sonography? The case for hysteroscopy.

Office hysteroscopy for the diagnosis and management of abnormal uterine bleeding has developed into an easily performed procedure, with minimal discomfort and significantly reduced risks and expense. Miniaturization of instruments and safer liquid distention media, along with effective local analgesia, have made the procedure a fast, effective, and much more precise way to detect intrauterine abnormalities, as well as to better define the correct plan for any proposed operative management. In addition to the above, hysteroscopy is considered the "gold standard" for evaluating the uterine cavity. Numerous studies comparing hysteroscopy to sonography, with or without saline solution infusion are cited, along with other studies comparing hysteroscopy to blind biopsy and curettage, all indicating that hysteroscopy is more accurate, with fewer false-positive and false-negative results.

Vessel sealing using a pulsed bipolar system and open forceps.

We evaluated the vessel-sealing ability of one application of a pulsed plasma kinetic (PK) electrosurgical device on skeletonized vessels up to 7 mm in diameter to withstand sustained pressure of 300 mm Hg using bench and animal models. Forty-six porcine specimens and 66 abattoir vessels (112 total) were pressure tested after sealing with a pulsed PK system. Of these, 108 (96%) met the criterion of 300 mm Hg pressure held for 10 seconds without leaking. The PK system open forceps effectively closes vessels and maintains closure at a pressure level sufficient for clinical use. The device is more effective than clips, sutures, and staples.