Department of Obstetrics and Gynaecology, Antoine Béclère Hospital, AP-HP, 157, Rue de la Porte de Trivaux, 92140 Clamart Cedex, France
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Abstract |
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Key words: bipolar electrode/hysteroscopic surgery/normal saline solution
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Introduction |
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In order to decrease these complications, we used a new coaxial bipolar electrode surgical system, effective in saline solution, through the `5' French (5F) operating channel of a 5.5 mm hysteroscope.
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Materials and methods |
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Each electrode consists of an active electrode located at the tip and a return electrode located on the shaft, separated by a ceramic insert. Only tissue in contact with the active electrode involved in the electrical path circuit will be desiccated or vaporized. Similar to other electrosurgical equipment, the generator is designed to be located outside the sterile field with adjustment of settings performed by ancillary operating staff. The generator provides five modes of operation (waveforms) and different power settings between 1 and 200 W. The selected mode of operation and the power setting is indicated on the generator display. The vaporize and blend acronyms of vapour cut, `VC1', `VC2', `VC3' and Blend, `BL1' and `BL2' waveforms are assigned the traditional `cut' (yellow pedal) and are used to vaporize and excise tissue. The `DES' acronym for desiccate waveform is assigned to the traditional coagulation mode (blue pedal) and is used for haemostasis. There is only ~1 mm2 area of collateral damage to tissue. The generator is connected to the electrode via a flexible cable. The electrodes are designed for insertion down the 5F working channel of the 5.5 mm hysteroscope (Karl Storz GmbH & Co, Tuttlingen, Germany).
When the electrode type is connected to the generator, a key feature of the system is its ability to detect the type of electrode attached and to adjust automatically the default power settings to the optimal level for each electrode type. The surgeon can change the default power settings as required. We used, for this reproductive surgery, 130 W. Normal saline in a 1 l bag as the distension medium. Each bag was then adapted in an automatic rotary pump (Hamou-Endomat; Karl-Storz). The flow rate was then constant at no more than 400 ml/mm. Monitoring was performed by measurement of the difference between fluid consumption and aspiration.
Patients
To gain experience with this new system, we first treated 50 patients with endometrial polyps and submucous myomata who had experienced perimenopausal menorrhagia. After this initial learning experience, we treated 40 patients with surgically remediable lesions associated with infertility between 1 January 1999 and 1 February 2000.
Uterine pathology was documented either by hysterosalpingography or transvaginal sonography and diagnostic hysteroscopy.
In this pilot study, the inclusion criteria were hysteroscopic surgical correction of submucous myomata with a size <2 cm (n = 12), uterine septum (n = 12), intrauterine adhesions grade III (according to the European Society of Hysteroscopy: Wamstefer and De Block, 1993) (n = 11) and uterine hypoplasia (n = 5) defined by T-shaped uterus.
No patient had previous uterine surgery. Moreover, all patients underwent investigation of infertility including hormonal evaluation on day 3 of the cycle (FSH, LH, oestradiol), which was normal in all cases, and partner sperm analysis. Five patients had male infertility. Ten patients also had a hysterosalpingography showing tubal or peritubal abnormalities. No endometrial suppressive treatment was given preoperatively. Patients with acute cervicitis and active pelvic inflammatory disease were excluded.
Hysteroscopy was first performed to confirm the uterine lesion and then the electrode was used to vaporize or excise these lesions. Visualization was not affected by the creation of bubbles or tissue debris, which were always absent. The hysteroscopic metroplasty consisted of incising the lateral spurs to obtain an enlargement of uterine size and an improvement in uterine shape.
In this study, general anaesthesia was systematically performed. Twenty-five patients required concurrent laparoscopy for visualization of the pelvic organs and a chromotubation test. In the other 15 patients, 10 laparoscopies had been previously performed in other surgical departments and five were not indicated because of associated male infertility, with indication for intracytoplasmic sperm injection.
Post-operative hysteroscopy was systematically indicated after treatment of intrauterine adhesions (n = 11) and uterine hypoplasia (n = 5) due to the risk of post-operative synechiae. In one case we performed a post-operative hysteroscopy because the initial septum was particularly large.
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Results |
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All the procedures were completed using a 1 l bag of normal saline solution. The amount of saline absorbed systemically ranged from 100 to 300 ml. Diuretics were never required. Leakage of fluid around the hysteroscope was frequently observed.
Among the 25 concurrent laparoscopies, 15 identified normal pelvic anatomy, five periadnexial adhesions (score AFS 1 and 2; American Fertility Society, 1985), three endometriosis (score AFS 1 and 2) and two hydrosalpinx which required neosalpingostomy.
Seventeen patients had a systematic post-operative control hysteroscopy at 2 months. No synechiae were observed and no second surgery was indicated. During this short follow-up period, 10 normal intrauterine ongoing pregnancies (25%) occurred with no recurrence of abortion.
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Discussion |
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A second advantage of the bipolar electrode system is that cervical dilatation is not required. Such dilatation is often difficult in nulliparous women with a stenotic cervix. Avoiding cervical dilatation should prove advantageous in reducing the risk of cervical laceration and uterine perforation and in post-operative analgesia requirements.
A third potential advantage is that this bipolar system might prevent electrosurgical genital tract burns, previously reported (Vilos et al., 1997, 2000
). The return electrode must always be exposed and lie outside the sheath of the hysteroscope to complete the circuit and achieve the most efficient vaporization.
Having optimized our technique in the initial cohort of 50 patients, we were able to operate more quickly than with the usual monopolar technique. Lesions located within the lower uterine segment in close proximity to the internal os (particularly synechiae) still posed some degree of technical difficulty.
Excellent haemostasis was achieved in the vapour cut mode requiring the infrequent desiccation mode which is likely to be advantageous in infertility surgery. Total vaporization of the myomata also avoids the process of having to remove chips from the field of vision and this contributes to the decrease in operating time. All intrauterine lesions should be biopsied prior to complete vaporization to minimize the risk of missing a malignancy.
In conclusion, the Versapoint® bipolar electrosurgical system appears advantageous in infertility surgery. Those experienced with operative hysteroscopy should be able to adapt readily to this new technique. Our results confirm the preliminary experiences previously published in prospective, uncontrolled pilot studies with intrauterine pathology (Kung et al. 1999; Vilos, 1999
; Lindheim et al., 2000
), but many hundreds of patients must be operated on using this device in order to determine its safety and the degree and type of various complications. In the future, some of these operative hysteroscopies could be conducted without need of general anaesthesia using a paracervical block with or without intravenous sedation in selected patients.
This bipolar electrosurgical system may become an effective alternative to traditional modalities for infertility surgery.
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Notes |
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References |
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Submitted on March 16, 2000; accepted on May 12, 2000.