Hysteroscopy and falloposcopy are routine procedures in gynecological endoscopy. Injuries to the cervix or uterine perforations due to blind manipulation or wrong use of instruments are the most common complications associated with these procedures. In vitro simulators have been shown to be valuable tools in the laparoscopic training of physicians. Therefore we developed a simulator for hysteroscopy offering realistic anatomical and physiological training conditions. Additionally, we examined different polymer substances as basic materials for organ modules that allow the realistic application of electric instruments, e.g. resector blades and rollerball.
Adenomyosis, a disease of the myometrium, can be diagnosed by hysteroscopy. Histologic specimens removed by transcervical punch biopsies or loop resection give more information on the depth of the adenomyosis. Symptomatic superficial adenomyosis can be treated sufficiently by transcervical endometrial coagulation or resection but can lead to iatrogenic adenomyosis, which can be treated by second-look hysteroscopy. Adenomyosis may also be caused by incomplete transcervical endometrial ablation or resection. In selected cases, hysteroscopic treatment of symptomatic focal adenomyosis becomes possible.
Although postmenopausal bleeding (PMPB) is a frequent problem in clinical practice and as such has major clinical relevance, the management strategies are often quite different. This review, after an introduction describing the various causes of PMPB, analyses in which order diagnostic procedures are indicated. There is much concern in decreasing the rate of invasive procedures; this is possible with the aid of transvaginal ultrasound (TVS) which is very reliable in excluding endometrial cancer at a thickness of < or = 4 mm. The vast majority of benign and malignant endometrial changes have an endometrial thickness of > 4 mm. Since the specificity of TVS for a pathological finding at a thickness of > 4 mm is low, other investigations are needed. Saline infusion sonohysterography (SIS), an easy complementary tool to TVS, and office hysteroscopy seem to give the same results, the first one being better accepted by the patients, the latter permitting biopsies and resections to be performed at the same time. Anyway, in all these cases a histological diagnosis is mandatory (endometrial biopsy/D&C/hysteroscopic resection). In cases of persisting or recurrent PMPB, independent of the TVS result, a hysteroscopy (with biopsy and/or resection) is mandatory.
Whereas cervical carcinoma is reliably detectable by the noninvasive methods of cytological/cervical smear and HPV typing even in the early stages, endometrial carcinoma thus far eludes effective check-up. Neither ultrasound nor invasive procedures such as Pipelle de Cornier, abrasio fracta or hysteroscopy, succeeded in making the majority of endometrial carcinomas detectable at an early stage in systematic screenings. Several factors contribute to this fact: first, only a fraction of these carcinomas develops through early stages of atypical hyperplasia, whereas the majority develops de novo. As the most suitable screening method in general, ultrasound fails in pre- and perimenopausal women, who account for 30% of new endometrial carcinoma cases. Moreover, patient compliance with preventive examinations is especially low in the high risk population of senior women. And, finally, there are issues regarding the clinical consequences of improved diagnosis, since endometrial carcinomas may become clinically significant in only 1 of every 4-6 patients, whereas the majority of these malignomas remains clinically inapparent. Hence, atypical uterine bleeding will continue to be the main symptom prompting hysteroscopic and histological clarification (H&H) and ensuing detection of endometrial carcinomas and their early stages.
Hydrothermablation is a new method which could replace the electrosurgical method of endometrial ablation. Some prospective studies were carried out to assess efficacy, safety and tolerability of hydrothermablation in the treatment of recurrent menorrhagias. Hydrothermablation is an intervention with coagulation at the endometrium: temperature 90 degrees C and duration 10 min with simultaneous hysteroscopic control. In a follow-up of least 12 months, about 35% of the patients had an amenorrhea and the treatment was successful (reduction of pathological blood flow) in about 87% of the patients. Complications were vaginal burns in 2 cases. No other intra- or postoperative complications occurred. Hydrothermablation is a safe and effective method for treatment of recurrent menorrhagias. This method offers a simple possibility to perform endometrial ablation without extensive training of the surgeon and can contribute to avoid hysterectomy.
Hydrothermablation is a new method which could replace the electrosurgical method of endometrial ablation. Some prospective studies were carried out to assess efficacy, safety and tolerability of hydrothermablation in the treatment of recurrent menorrhagias. Hydrothermablation is an intervention with coagulation at the endometrium: temperature 90 degrees C and duration 10 min with simultaneous hysteroscopic control. In a follow-up of least 12 months, about 35% of the patients had an amenorrhea and the treatment was successful (reduction of pathological blood flow) in about 87% of the patients. Complications were vaginal burns in 2 cases. No other intra- or postoperative complications occurred. Hydrothermablation is a safe and effective method for treatment of recurrent menorrhagias. This method offers a simple possibility to perform endometrial ablation without extensive training of the surgeon and can contribute to avoid hysterectomy.
The aim of this observational clinical study was to evaluate the feasibility and diagnostic accuracy of outpatient diagnostic hysteroscopy in premenopausal patients suffering from abnormal uterine bleeding. Between September 1996 and September 1999, 819 patients were referred to our outpatient hysteroscopy clinic, 317 of which were premenopausal, and presenting with menstrual symptoms. All hysteroscopies were performed using a standard 30 degrees 5-mm hysteroscope, and the uterine cavity was generally distended with normal saline. Hysteroscopy was completed successfully in 305 cases (96.2%), but since the routine use of lidocaine spray in 1998 this figure increased up to 98.9%. Intrauterine pathology was diagnosed in almost 34% of patients, the most frequent being submucous myomas (14%) and endometrial polyps (14%); there was no case of endometrial cancer in this subset of patients. Moreover, there was an age-related distribution of intrauterine pathology, with the highest incidence in patients aged 41-50 years. Diagnostic hysteroscopy is a simple and safe technique, well accepted by the vast majority of patients; due to its excellent diagnostic accuracy, and its high success rate as an outpatient procedure, we wonder why inpatient D&C under general anesthesia is still regarded a diagnostic or even therapeutic option for patients with abnormal uterine bleeding.
Hysteroscopic surgery is widely used for the treatment of patients suffering from infertility and menorrhagia. Preoperative and postoperative treatment plays an important role in this kind of surgery. The indications for hormonal pre- and postoperative treatment are very different and depend on the type of surgery and the condition of the patient. For a septum dissection, preoperative treatment is not necessary. Postoperative estrogen therapy can be helpful especially after dissection of a large septum. For intrauterine adhesiolysis, preoperative treatment is without benefit. In cases of adhesions of grades 3 and 4, postoperative treatment entailing insertion of an IUD and application of estrogens for about 3 months is recommended. A higher amenorrhea rate after endometrium ablation can be reached by pretreatment with a GnRH analogue or danazol. For resection methods, pretreatment is not necessary in any case. The success rate of endometrium ablation (reduction of blood loss) is not influenced by pretreatment. Pretreatment can be useful in coagulation techniques in patients suffering from secondary anemia and in high-risk patient. In patients who need hormone replacement therapy after endometrium ablation, gestagen application is necessary. For prevention of bleedings, a continuous combined hormone replacement therapy should be used and so a bleeding-free treatment is possible. The residual endometrium will so be protected against hyperplasia. Another alternative postoperative method after endometrial ablation is insertion of a levonorgestrel IUS. Our studies show advantages for protection of the endometrium, for contraception and a high amenorrhea rate. Prior to a hysteroscopic myoma resection, pretreatment with GnRH analogues is indicated for all myomas with a diameter of more than 3 cm and/or an intramural portion or for patients suffering from secondary anemia. The aim of the pretreatment is not only to obtain a thin endometrium but also to reduce the size and vascularization of the myomas. The failure rate in patients not treated with GnRH analogues is higher especially in large intramural myomas. Pre- and postoperative hormonal treatment can be effective, especially in the treatment of patients suffering from menorrhagia. The indications for hormonal pre- and postoperative treatment should be very strong. A hysteroscopic surgeon should be also have some experience in hormonal treatment.
During the last few years, diagnostic hysteroscopy has become a standard procedure in the diagnosis of abnormal uterine bleeding, sonographically suspicious endometrial reflex and fertility disorders. At the same time the hysteroscopic treatment of intrauterine pathology is becoming more common. Today, hysteroscopic resection of uterine myomas, dissection of uterine septa, and endometrial ablation are standard procedures. Using monopolar cutting devices and saline-free distension media, hysteroscopic surgery bears specific risks. The knowledge of these risks is important to avoid typical complications of operative hysteroscopy. This article gives an overview about the most common procedures of operative hysteroscopy and the combined risks. Criteria for a safe procedure are defined in order to increase the quality management of operative hysteroscopy.
Within just a few years, operative hysteroscopy has largely replaced laparotomy in the treatment of submucous myomas. Due to the rapid expansion of hysteroscopic surgery techniques, guidelines must be defined to standardize the procedure and at the same time provide the basis for highly individualized treatment of each patient. The choice of an appropriate therapeutic approach in this context is an issue of logistics, rather than surgery. Factors contributing to the individualized decision regarding the therapeutic approach include indications, individual anatomical conditions encountered, necessity of medical pretreatment, available equipment and adequate premises at the surgical center, and intraoperative procedure of choice. Taking into consideration all these issues, the present article aims at presenting to the surgeon not only a summary of the state-of-the-art techniques, but also a guideline for sophisticated strategy planning for and performance of the hysteroscopic technique of myoma resection.
Greatly thickened endometria are often observed in vaginal sonography in patients taking tamoxifen. The incidence of type I carcinoma of the endometrium is also raised under tamoxifen. Both effects are ascribed to the known partial estrogenic effect of tamoxifen. However, if sonographically hyperplastic endometria are abraded, mostly only atrophic material is obtained. To clarify this contradiction, 89 patients treated with tamoxifen were investigated by means of vaginal sonography at intervals of 6 months. In 33 of them (37%), an endometrial thickness > 8 mm was found. In order to investigate the endometrial thickness throughout, a hysteroscopic loop resection (polyps n = 18, diffuse hyperplasia n = 15) and afterwards histological work-up of the endometrium in serial sections were carried out in all these patients. Hyperplasia of the endometrial stroma without cellular atypia was found in all cases. However, the glandular epithelium was always atrophic. This explains the contradiction between sonographically thick endometrium (stromal hyperplasia) and the scanty abrasion material (atrophy of the glandular epithelium). The 'hyperplasia' found sonographically is not necessarily estrogen-dependent hyperplasia of the glandular epithelium leading to a carcinoma. This raised the question as to the etiological reasons for the increased incidence of carcinomas. We discuss the hypothesis that tamoxifen may also promote the conversion of pre-existent subclinical lesions into manifest carcinomas.
Diagnostic hysteroscopy should be included routinely in the work-up of invasive examinations for infertility patients. Anyhow, one can rarely expect to find the definite underlying reason for infertility. In infertile patients about 20% of hysteroscopic examinations show some grade of intrauterine abnormalities. Congenital uterine malformations are the most frequently found disorders. In the group of patients with habitual abortions abnormalities are found much more often and can also be more often interpreted as the mainly underlying factor for the repeated abortions. Operative hysteroscopy has become the surgical method of first choice for the treatment of uterine septa, submucous myomas, polyps and synechia. After septum dissection results are excellent. Myoma removal also shows beneficial effects on fertility; nevertheless, cases are not too frequent among infertility patients. In cases of high-grade Asherman's syndrome, the prognosis after hysteroscopic surgery is still often poor.
Hysteroscopy and falloposcopy are routine procedures in gynecological endoscopy. Injuries to the cervix or uterine perforations due to blind manipulation or wrong use of instruments are the most common complications associated with these procedures. In vitro simulators have been shown to be valuable tools in the laparoscopic training of physicians. Therefore we developed a simulator for hysteroscopy offering realistic anatomical and physiological training conditions. Additionally, we examined different polymer substances as basic materials for organ modules that allow the realistic application of electric instruments, e.g. resector blades and rollerball.
Transvaginal sonography is an established method for numerous clinical indications in the assessment of endometrium pathology. The investigation of the endometrium consists of the measurement of the thickness, the visualization of the echogenity and echotexture and of the demonstration of focal masses. However, evaluation of the uterine cavity by transvaginal sonography is limited and an abnormal ultrasound of the endometrium may reflect benign or malignant conditions. Furthermore, small structures can be missed or overlooked. If indicated, hydrosonography offers various advantages compared to dilatation and curettage and hysteroscopy in terms of costs, availability and risks. Additional informations obtained after hydrosonography may influence the management before consideration of curettage or hysteroscopy.
Approximately 20-25% of hysterectomies are done for the relief of menorrhagia, excessive menstrual bleeding without gynecologic pathology. Menorrhagia represents a widespread clinical problem, and it is one of the leading causes of elective hysterectomy in women with a normal uterus in the US as well as in Europe. The current management of dysfunctional bleeding includes medical or different types of surgical therapies. When patients wish a nonsurgical therapy for menorrhagia we can offer them different medical treatments, a IUD releasing levonorgestrel or a therapeutic dilatation and curettage (D&C). Until recently, women who did not respond to medication were limited to either hysterectomy or continued cycles of heavy menstrual bleeding. Methods for hysteroscopic endometrial ablation were introduced in the 1980s including Nd:YAG laser ablation, transcervical resection of the endometrium (TCRE) and 'rollerball' electrocoagulation (RBE). These first-generation procedures are nowadays the gold standard for the hysteroscopic treatment of menorrhagia. In the 1990s different types of therapeutic alternatives were introduced. The second generation of hysteroscopic ablation techniques include: balloon heating methods, methods with intrauterine instillation of heated saline, the endometrial laser intrauterine thermal therapy procedure ELITT using a diode laser, global 3-D bipolar ablation method, punctual vaporizing methods, photodynamic endometrial ablation method, microwave endometrial ablation method, the radiofrequency method menostat and a cryotherapy method.
Endometrial resection (TRCE) is a well-examined alternative therapy to hysterectomy in the treatment of menorrhagia that preserves the uterus at long term in at least 70% of patients. The technique and safety considerations are described and an overview of the existing evidence is given. Complication rates (2.5%) and performance of the personal series of 465 operative hysteroscopies including 244 endometrial resections with a follow-up of at least 18 months are shown. 3.3% of patients with endometrial resection needed a hysterectomy up to now (follow-up 18-90 months). The combination of endometrial resection and the insertion of the levonorgestrel hormone-releasing intrauterine device (LNG-IUD) is described. Especially in patients with adenomyosis, the combination of LNG-IUD with endometrial resection augments the success rate. 96 of 99 patients with the combined therapy (TRCE and LNG-IUD) and a follow-up of 18-48 months still have their uterus.
Dysfunctional uterine bleeding (DUB) has emerged as one of the most frequently encountered gynecological problems. Besides the problems with anemia and iron deficiency, excessive menstrual bleeding adversely affects quality of life and contributes to health-care costs as it is a major indication for referral to the gynecological outpatient clinic. It is a disabling problem for many women and a major clinical challenge for gynecologists. There are numerous options for the treatment of DUB: drug therapy, hysterectomy, endometrial ablation with the Nd:YAG laser, resectoscope, rollerball, and more recently other alternatives such as bipolar devices, direct hot saline instillation, microwaves, and thermal balloons.
