Hysteroscopy: a technique for all? Analysis of 5,000 outpatient hysteroscopies.

OBJECTIVE: 1) To investigate the relationship between operator experience and the success of outpatient hysteroscopy; and 2) to determine if the introduction of normal saline and the use of narrow-caliber hysteroscopes and vaginoscopic approach are associated with a lower failure rate. DESIGN: Retrospective study. SETTING: Teaching-hospital based outpatient hysteroscopy clinic. PATIENT(S): Five thousand consecutive women undergoing outpatient hysteroscopy between October 1988 and June 2003. INTERVENTION(S): The hysteroscopies were carried out both by experienced operators and by trainees. Procedures were performed using 4-mm and 2.9-mm telescopes with 5-mm and 3.5-mm diagnostic sheaths, respectively. Between October 1988 and 1996, the uterine cavity was distended with CO(2) (CO(2) period), whereas normal saline was preferred after 1997 (1997-2003: saline period). Traditional technique of hysteroscope insertion and vaginoscopic approach were used depending on operator preference and experience and patient characteristics. MAIN OUTCOME MEASURE(S): Success, failure, and complication rates. RESULT(S): The hysteroscopies were successfully performed in nearly 95% of cases by 362 operators (mean 13.8 hysteroscopies per operator) with different levels of expertise. Failure and complication rates were 5.2% and 5.4%, respectively, without any significant difference between CO(2) and saline periods. Vasovagal attacks and shoulder pain were significantly higher during the CO(2) period. The success of outpatient hysteroscopy was negatively affected by postmenopausal status, nulliparity, need for cervical dilatation or local anaesthesia, traditional technique of hysteroscope insertion, and use of a 5-mm hysteroscope. CONCLUSION(S): A high level of expertise is not a prerequisite to performing hysteroscopy on an outpatient basis. Recent advances in technique and instrumentation facilitate this approach and might encourage greater adoption by the wider gynecology community.

Surgical and radiological management of uterine fibroids--a UK survey of current consultant practice.

BACKGROUND: The aim of this study was to determine the current surgical and radiological management of uterine fibroids by consultants working in the UK. METHODS: A structured questionnaire was posted to all 1439 UK consultants. Non-responders were sent one reminder. The main outcome measures were surgical route and technique used for myomectomy, and the use and availability of uterine artery embolization (UAE). RESULTS: Eight hundred fifty-two (59%) consultants replied. Seven hundred thirty-five (86%) admitted to regular sessions of gynecologic surgery, and 75% of this group performed open myomectomy, 16% laparoscopic myomectomy, and 66% hysteroscopic myomectomy. Open myomectomy: Forty-one percent of consultants performed open surgery on uteri equivalent to 12-week gestational age or less, 87% prescribed preoperative gonadotrophin-releasing hormone agonists (GnRHa) in order to reduce surgical bleeding, with 35% using myomectomy clamps, 23% tourniquets, and 19% vasoconstrictors. Laparoscopic myomectomy: The largest uterine size the majority would attempt was equivalent to a 12-week gestation, 58.6% used preoperative GnRHa, 21% used intraoperative vasoconstrictors, and 1.4% tourniquets in order to minimize bleeding. Hysteroscopic myomectomy: As with laparoscopic myomectomy, the largest uterine size the majority would attempt was equivalent to a 12-week pregnancy. Blood transfusion: Twenty per cent, 10%, and 7% reported the need for blood transfusion in up to 10% of patients undergoing open, laparoscopic, or hysteroscopic myomectomy, respectively. UAE: Fifty-one percent have access to UAE and 40% have referred at least one patient in 2001. CONCLUSIONS: Open and hysteroscopic myomectomy are frequently utilized in contrast to laparoscopic myomectomy. The reported rate of blood transfusion appears low. Although UAE is widely available, the majority of patients are still managed surgically.

Chronic ectopic pregnancy diagnosed incidentally in an infertile woman: a case report.

BACKGROUND: Chronic ectopic pregnancy is an enigma. The clinical presentation can be mild, with absent or subtle symptoms. The high incidence of negative pregnancy tests and the poor specificity of sonographic patterns can be misleading, and the correct diagnosis is sometimes established only at surgery or even histopathologically after the operation. We report the first case of a woman who was accidentally diagnosed with chronic ectopic pregnancy during diagnostic laparoscopy performed as part of a routine investigation for primary infertility. CASE: A 28-year-old woman underwent laparoscopyfor infertility. She had a regular menstrual cycle and was asymptomatic. She gave a history of a possible but unconfirmed miscarriage earlier. Her hormone profile was normal apart from a slightly raised prolactin level. An earlier ultrasound showed a polycystic appearance of the ovaries. Laparoscopy was done on the 25th day of the menstrual cycle, and beta-human chorionic gonadotropin was negative. At laparoscopy, a 2-cm mass wasfound in the right fallopian tube. There was no free blood in the pelvis, and no adhesions. Both tubes were patent at hydrotubation. The mass was excised laparoscopically, and histology confirmed a diagnosis of chronic ectopic pregnancy. CONCLUSION: A review of articles on chronic ectopic pregnancy confirmed the difficulty in diagnosing this condition preoperatively.