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Abstract: Study objective: To compare 2 procedures for metroplasty: resectoscopy with monopolar knife versus small-diameter hysteroscopy fitted with a Versapoint device. Design: Prospective randomized study (Canadian Task Force classification I). Setting: Endoscopic gynecology units at tertiary care university hospitals. Patients: One hundred-sixty patients with septate uterus and a history of recurrent abortion or primary infertility undergoing hysteroscopic metroplasty from 2001 to 2005. Interventions: Hysteroscopic resection of the uterine septum performed with either a 26F resectoscope with unipolar knife (80 women, group A) or a 5-mm diameter hysteroscope with Versapoint device (80 women, group B). All patients were managed expectantly, with follow-up lasting 1 year. Measurements and main results: Operative parameters (operative time, fluid absorption, complications, need for second intervention) and reproductive outcome parameters (pregnancy, abortion, term and preterm delivery, modality of delivery, cervical cerclage) were measured. Operative time and fluid absorption were significantly greater in group A than in group B (23.4 ± 5.7 vs 16.9 ± 4.7 minutes and 486.4 ± 170.0 vs 222.1 ± 104.9 mL, respectively). The cumulative complication rate was significantly lower in group B than in group A. No difference in any of the reproductive parameters was observed between the 2 groups: pregnancy and delivery rates were 70% and 81.6% in group A vs 76.9% and 84% in group B. Nine women (18.4%) from group B and 8 women (16%) from group B experienced spontaneous abortions. Most patients (54/82) delivered by cesarean section without differences according to the hysteroscopic technique used for metroplasty (65% in group A vs 67.7% in group B) or to the gestational age (65.1% of term and 68.7% of preterm deliveries). Conclusions: Small-diameter hysteroscopy with bipolar electrode for the incision of uterine septum is as effective as resectoscopy with unipolar electrode regarding reproductive outcome and is associated with shorter operating time and lower complication rate. [Copyright &y& Elsevier]

Abstract: This case report describes a new treatment of an isolated longitudinal vaginal septum (LVS) by office operative vaginoscopy with a 4-mm rigid hysteroscope in a 27-year-old virgin who reported leukorrhea and recurrent vaginal infections. This technique might represent an effective treatment of an LVS, mostly in patients with an intact hymen. This could allow the inclusion of vaginal lesions among the indications for office endoscopic procedures performed using operative hysteroscopes. [Copyright &y& Elsevier]

Abstract: Study objective: A key component of hysteroscopic complications, such as fluid overload and severe dilutional hyponatremia, is the failure to anticipate and quickly recognize fluid deficits. The purpose of this study was to measure the volume and mass of irrigation fluid bags to assess the overfill of 3 common types of hysteroscopy irrigation fluids, 0.9% normal saline solution, 3% sorbitol, and 1.5% glycine, to challenge the often-quoted standard of assumption that overfill may be as high as 10% of the bag’s volume. Design: Ten cases of irrigation fluid were tested. The volume and weight of drained fluid from 18 bags of 0.9% normal saline solution 2000 mL, 12 bags 3% sorbitol 3000 mL, 8 bags of 1.5% glycine 3000 mL, and 4 bags of 0.9% normal saline solution 5000 mL were measured. Institutional review board exemption was obtained. Measurements and main results: Ten cases of irrigation fluid were obtained. The volume and weight of drained fluid from 18 bags of 0.9% normal saline solution 2000 mL, 12 bags of 3% sorbitol 3000 mL, 8 bags of 1.5% glycine 3000 mL, and 4 bags of 0.9% normal saline solution 5000 mL were measured. By volume, varying by the type of fluid tested, the maximum observed overfill was between 3.3% to 5.0%. For confirmation, each bag was also weighed and found to have a maximum overfill between 2.8% to 5.6%, varying with the volume and type of fluid measured. These findings were then compared with the manufacturer-provided overfill range of 1.5% to 6.0%. No underfill was observed. Conclusion: Contrary to assertions over the last 25 years that overfill is 10% or higher as a rule, it appears more reasonable to assume that the degree of overfill is contingent on the type and volume of fluid used and is more likely closer to 2.8% to 5.6%. Therefore an accurate collecting system and weight measurement is more precise. [Copyright &y& Elsevier]

Abstract: Hysteroscopy today represents 200 years of salient innovations in instrumentation, new clinical applications for existing instruments, and continual modification of techniques, all aiming at observing, diagnosing, and treating pathologic conditions of the uterine cavity. Pioneers established the fundamental principles of intrauterine observation that steady technological advances would simplify and refine, all the way to the instrumentation and ancillary equipment now in use. Homage should be given and tribute paid to predecessors who made instrumentation, intrauterine distention, and illumination safe and practical for diagnostic and therapeutic hysteroscopy. Their accomplishments are remembered as we look with optimism to the many advances that undoubtedly will mark the future of hysteroscopy. [Copyright &y& Elsevier]

Abstract: Study objective: To evaluate the benefits of adopting 3 simple “diagnostic criteria” in the differential diagnosis between septate and bicornuate uteri, and the relative treatment by hysteroscopy in an office setting. Design: Prospective clinical study (Canadian Task Force classification III). Setting: University-affiliated hospital. Patients: Two hundred-sixty patients with a hysteroscopic diagnosis of a double uterine cavity were enrolled. Interventions: Office hysteroscopic metroplasty was performed without analgesia or anesthesia using 5F scissors. Measurements and Main Results: The presence of vascularized tissue, sensitive innervation, and the appearance of the tissue at the incision of a supposed septum during an office hysteroscopic procedure were the criteria used to differentiate a septate from a bicornuate uterus. In 93.1% of the cases, office hysteroscopic metroplasty was successfully performed during the same diagnostic procedure. In 15 of 18 patients scheduled for laparoscopic control of the uterine anatomy, the suspicion of a bicornuate uterus was confirmed. Hysteroscopic follow-up at 3 months showed a regular uterine cavity with a fundal notch less than 1 cm. Conclusion: The study demonstrates the possibility of obtaining complete, safe removal of uterine septae in most cases by office hysteroscopy confirmation, using mechanical instruments, in an office setting. This was achieved by relating the diagnosis and treatment to simple anatomic and physiologic diagnostic criteria. [Copyright &y& Elsevier]

Abstract: In order to assess the efficacy of uterine polypectomy in the treatment of abnormal uterine bleeding (AUB), we conducted a systematic review of the published literature. Relevant papers were identified through electronic scanning of MEDLINE (1966–2004), EMBASE (1980–2004), and the Cochrane Library, and manual searching of bibliographies of known primary and review articles. Studies were selected if the efficacy of uterine polypectomy in treating women with AUB (menstrual dysfunction, postmenopausal bleeding with or without hormone replacement/tamoxifen therapy) was estimated. Study selection, quality assessment, and data abstraction were performed independently and in duplicate. The main outcomes measured were relief of AUB symptoms measured in general terms (improvement from baseline, normalization of bleeding patterns) and patient satisfaction. Secondary outcomes included technical feasibility and complications. Ten uncontrolled observational studies with 617 women were identified. No randomized trials were found. The methodologic quality of included studies was poor. Hysteroscopic resection under general anesthesia was used to remove intrauterine polyps in all studies, although outpatient approaches with local anesthetic also were employed in three of these case series. No technical failures were reported, but three complications including one uterine perforation were described. All studies reported an improvement in symptoms of AUB after polypectomy (range 75%–100%) at follow-up intervals of between 2 and 52 months. A single study compared outpatient polyp removal under local anesthesia with inpatient, general anesthetic treatment and detected no significant difference in treatment outcomes (p = 0.7). It was only possible to stratify treatment outcome according to type of AUB in one small study, which detected no significant difference between polypectomy for menstrual dysfunction or postmenopausal bleeding (p = 0.2). In conclusion, there is a lack of high-quality evidence to reliably inform clinical practice regarding the efficacy of intrauterine polypectomy in women with AUB. The limited available evidence suggests that hysteroscopic polypectomy is a technically successful procedure that improves AUB symptoms. Further research in the form of a multicenter, randomized, controlled trial, stratified by technique, setting, and pattern of AUB, is required to assess the short- and long-term effects of this commonly practiced intervention. [Copyright &y& Elsevier]

Abstract: Study objective: To evaluate whether hysteroscopic imaging can contribute to decrease the rate of undetected endometrial carcinomas concurrent with atypical hyperplasia diagnosed by endometrial biopsy. Design: Retrospective study. Design Classification: Canadian Task Force Classification II-3. Setting: Public hospital. Patients: Hysteroscopic reports of 25 menopausal patients undergoing endometrial biopsy yielding a diagnosis of atypical hyperplasia were reviewed. On the basis of this diagnosis, all patients were treated by hysterectomy, and the pathologic findings on the uterine specimen were correlated with the diagnoses obtained by hysteroscopic view. Interventions: Hysteroscopy was video-assisted and carried out with normal saline solution used as liquid distension medium; a 5-mm sheathed hysteroscope, with a working channel, was used for each examination. After hysteroscopic inspection, an endometrial sampling targeted under vision was performed by mechanical or electrosurgical instrumentation. When extensive features of hyperplastic or neoplastic growth were observed, we combined a blind sampling procedure with Vabra-curettage. We calculated the sensitivity, specificity, and negative and positive predictive values of hysteroscopic inspection to foresee the diagnosis of endometrial cancer incidentally detected on hysterectomy specimen. Measurements and main results: On the basis of histopathologic study of uterine specimens, non atypical hyperplasias were detected in 3 patients, the diagnosis of complex atypical hyperplasia was confirmed in 11 patients, whereas a concurrent infiltrating endometrial adenocarcinoma was detected in 11 patients (44.0%). In the 14 patients with diagnosis of endometrial hyperplasia, no feature suggesting endometrial malignancy was reported by hysteroscopic inspection. In the 11 cases showing infiltrating carcinomas, hysteroscopic view was consistent with endometrial malignancy in 9 patients and with endometrial hyperplasia in 2 patients. An intramucous endometrial carcinoma without evidence of myometrial invasion was found on hysterectomy specimens of these two latter patients. From these figures, sensitivity, specificity, and negative and positive predictive values of hysteroscopy to foresee a diagnosis of infiltrating carcinoma were 84.6%, 100%, 87.5%, and 100%, respectively. Conclusions: Hysteroscopic view is a sensitive and specific method to identify among patients with a diagnosis of atypical hyperplasia on endometrial biopsy those with a coexisting infiltrating carcinoma. [Copyright &y& Elsevier]

Abstract: Study objective: To determine the prevalence and type of microscopic findings on laparoscopically resected uterosacral ligaments in women with chronic pelvic pain and no visible pelvic disease. The effect of this procedure on the patients’ level of pain also was assessed as a secondary objective. Design: Prospective follow-up (Canadian Task Force classification II-2). Setting: University-affiliated hospital. Patients: Twenty-seven premenopausal women undergoing diagnostic laparoscopy for chronic pelvic pain had a normal pelvis on visual inspection. All patients underwent resection and histologic evaluation of the uterosacral ligaments. Pain relief was evaluated by use of a questionnaire administered before and at 3, 6, and 12 months after surgery. Measurements and main results: Microscopic examination identified endometriosis in 2 (7.4%), endosalpingiosis in 3 (11.1%), and inflammation in 14 (51.9%) patients. Laparoscopic uterosacral ligament resection was associated with a reduction in dysmenorrhea (p ≤.001), with 14 (52%) patients reporting improved or resolved symptoms. There was a statistically significant decrease in dyspareunia (p ≤.01) and in the severity of noncyclical pain (p ≤.002). Thirty-five percent of patients no longer required medication for pain control (p ≤.005). The number of days needed off work also decreased. Conclusion: Despite normal laparoscopic appearance, microscopic endometriosis, endosalpingiosis, and inflammatory changes were found in uterosacral ligaments in 17 (63%) women with chronic pelvic pain. Laparoscopic resection of uterosacral ligaments improved dysmenorrhea, dyspareunia, and noncyclical pain and decreased the number of days lost from work, as well as the proportion of patients who required medication for pain control. © 2006 AAGL. All rights reserved. [Copyright &y& Elsevier]

Diagnostic hysteroscopy still is considered an invasive and painful technique. In recent years, a new technique based on the employment of minihysteroscopes with fluid distention and vaginoscopic approach has been proposed in order to improve feasibility and reduce pain and side effects. Size reduction of the hysteroscope is of greatest importance for reducing pain and risk of vasovagal reaction. In conclusion, the best approach in terms of ease, reliability, acceptability, and safety to patients in whom intrauterine exploration is indicated should be simple diagnostic hysteroscopy using a small-diameter, rod lens hysteroscope with a single-flow diagnostic sheath, vaginoscopic approach, and fluid distention. In this way in about 90% of patients, a correct diagnosis and proper choice for eventual subsequent operative strategy can be obtained, without discomfort and risk. [Copyright &y& Elsevier]

Abstract: Study objective: To evaluate the actual cost difference in performing Essure hysteroscopic sterilization in the office compared with ambulatory surgery using laparoscopic sterilization in the operating room. Design: Cost-comparison analysis (Canadian Task Force classification III). Setting: University hospital and affiliated outpatient office. Interventions: Hysteroscopic placement of Essure device in an office setting and laparoscopic tubal ligation for permanent sterilization. Measurements and main results: The various costs associated with the two procedures at our institution were compiled, and a direct cost comparison was made. We used actual institutional costs of the procedures, not billing or reimbursement. We found laparoscopic tubal ligations to cost $3449 compared with hysteroscopic placement of the Essure device that costs $1374 yielding a $2075 difference between the procedures. Conclusion: In our institution and in our experience, office-hysteroscopic placement of the Essure device is a more cost-effective method than laparoscopic tubal ligation. [Copyright &y& Elsevier]

Abstract: Study objective: We produced virtual hysteroscopy (VH) images from the images obtained after expanding the uterine cavity of patients with submucosal myomas and performing multidetector-row computed tomography scans, and assessed them in comparison with hysteroscopic imaging and in relation to the advantages of VH. Design: Cohort-control study (Canadian Task Force classification II-2). Setting: Tokyo Medical University Hospital department of obstetrics and gynecology. Patients: Thirty-one patients with submucosal myomas treated by endoscopic surgery. Measurements and main results: The expandability of the uterine cavity by CO2 gas was favorable in all 31 patients in whom imaging was performed, and it was possible to obtain clear VH images. The sites of origin of the submucosal myomas were clearly visualized; their imaging was consistent with imaging by hysteroscopy; and as a method of establishing the orientation of the uterine cavity, it was possible to obtain a greater amount of information than by hysteroscopy. Conclusion: Although the invasiveness of radiation exposure and contrast medium cannot be denied, the possibilities of and indications for VH, which by expanding and visualizing the uterine cavity enables the acquisition of navigation images of the uterine cavity that varies in morphology from patient to patient, are expected to continue to expand. [Copyright &y& Elsevier]

Abstract: Study objective: To evaluate the diagnostic accuracy of hysteroscopic view in endometrial hyperplasia. Design: Retrospective study (Canadian Task Force classification II-2). Setting: Public hospital in northern Italy. Patients: Three hundred twenty-three patients suffering from endometrial hyperplasia out of 2251 women (1119 premenopausal and 1132 postmenopausal) who underwent office-based hysteroscopy from January 1996 through May 2004. Intervention: Review of 2251 outpatient hysteroscopies carried out with 5- to 6-mm sheathed hysteroscopes and accomplished with blind or hysteroscopically targeted endometrial biopsies. Measurements and main results: The pathologic report was considered the reference test. Hysteroscopic detection of focal or extensive endometrial thickening, irregular vascular network, architectural distortion and crowding of gland openings, and gland cyst formation were considered endoscopic features consistent with hyperplasia. Overall sensitivity, specificity, negative predictive values (NPV), and positive predictive values (PPV) of hysteroscopy in order to foresee a diagnosis of hyperplasia were calculated. These figures were calculated both in premenopausal and postmenopausal patients. Histopathology yielded a diagnosis of simple, complex, and atypical hyperplasia in 247, 51, and 25 patients, respectively. Hysteroscopy foresaw hyperplasia in 38.4% of patients with simple hyperplasia and in 58.9% of patients with complex or atypical hyperplasia. Normal hysteroscopic findings underestimated simple hyperplasia in 34 patients (13.7%) and complex or atypical hyperplasias in 1 patient (1.3%) (p <.01). To predict the diagnosis of hyperplasia, hysteroscopy showed an overall sensitivity, specificity, NPV, and PPV of 63.7%, 91.7%, 91.3%, and 64.7%, respectively. Among premenopausal patients, hyperplasia was diagnosed in 134 women (11.9%); in this group, hysteroscopy showed sensitivity, specificity, NPV, and PPV of 65.6%, 88.5%%, 93.5%, and 50.5%, respectively. In postmenopausal patients, we found endometrial hyperplasia in 189 women (16.6%); sensitivity, specificity, NPV, and PPV of hysteroscopic view to anticipate hyperplasia were 61.6%, 95.2%, 89.3%, and 79.4%, respectively. A significantly better PPV to foresee hyperplasia was found in postmenopausal women compared with premenopausal patients (p <.01). Conclusions: Current hysteroscopic criteria suggesting endometrial hyperplasia are inaccurate; in order to exclude hyperplasia, a pathologic assessment is warranted in all hysteroscopies showing an irregularly lined or thick endometrium. [Copyright &y& Elsevier]

Transvaginal ultrasound has been utilized for first line evaluation of abnormal uterine bleeding since its development in the early 1980’s. The benefits and diagnostic effectiveness of transvaginal ultrasound in assessing the uterus, unlike hysteroscopy, extends to the complete pelvis. The ease of application, patient acceptance, and immediacy of results are rapidly apparent. Comparisons with hysteroscopic evaluation are discussed. While tissue diagnosis is still the gold standard, transvaginal sonography lets one know what surgical procedure to plan for from hysteroscopy to Endoscopy or laparotomy, including when no further surgical evaluation is necessary. [Copyright &y& Elsevier]

Study objective: We perform hysteroscopy in 14 women for the diagnosis and treatment of pathologic changes in the uterine cavity of women with an intact hymen. All hysteroscopies were successfully carried out with the hymen intact and the therapeutic results were excellent. Design: Retrospective study. Setting: University-affiliated hospital, department of obstetrics and gynecology. Patients: Fourteen unmarried women who underwent hysteroscopy on the condition of keeping the hymen intact. Interventions: Hysteroscopy was used for the diagnosis and treatment of pathological changes in the uterine cavity of women with an intact hymen. Measurements and main results: All 14 hysteroscopies were successfully carried out with the hymen intact, and the therapeutic results were excellent. Conclusion: Hysteroscopy without damaging the intact hymen is feasible and helpful for the diagnosis in the treatment of pathologic endometrial changes in women. [Copyright &y& Elsevier]