Department of General and Specialist Surgical Sciences, Section of Obstetrics and Gynecology, University of Bari, Italy
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Abstract |
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Key words: office hysteroscopy/patient acceptability/submucous myomas/uterine polyps/Versapoint bipolar electrode
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Introduction |
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In the last 10 years, technological improvements have led to the production of smaller diameter scopes. This has prompted the industry to develop sheaths which continue to have a final diameter of ~5 mm, as was the case in the old generation of purely diagnostic scopes, but this now includes the working channel and continuous flow features.
Another major advantage of these new instruments is their use of bipolar rather than monopolar energy. The advantages of bipolar over monopolar technology are well accepted in the medical field. The most important benefit in hysteroscopy is the use of saline solution rather than non-ionic distension media (i.e. glycine, sorbitol, mannitol, etc.), as well as the reduction of energy spread through the tissue during resection. These new scopes enable diagnostic and operative hysteroscopy to be performed simultaneously, in the office setting, without cervical dilatation and consequently without anaesthesia or analgesia (Bettocchi and Selvaggi, 1997).
In this paper we evaluate the benefits of minimally invasive techniques in hysteroscopy, focusing on the use of 5 Fr. bipolar electrosurgical equipment in the treatment of large benign intrauterine pathologies.
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Materials and methods |
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The electrosurgical instrument was the Versapoint Bipolar Electrosurgical System (Gynecare; Ethicon Inc., NJ, USA), consisting of a dedicated bipolar electrosurgical generator and two types of electrodes: the Twizzle, specifically for precise and controlled vaporization (resembling cutting) and the Spring, used for diffuse tissue vaporization (Figure 1). 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 in the electrical path circuit will be desiccated or vaporized. The generator provides different modes of operation (waveform): the vapour cut waveform, resembling a cut mode (the acronyms are VC1, VC2, VC3, where VC3 corresponds to the mildest energy flowing into the tissue), the blend waveform (BL1, BL2) and the desiccation waveform, resembling a coagulation mode (DES). The generator is connected to the 5 Fr. electrode via a flexible cable. Once connected, the generator automatically adjusts to the default setting (VC1 and 100 W).
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Patients
Since 1998, and up to April 2002, we have treated 501 patients (age range 1879 years) with single or multiple benign intrauterine pathologies observed during hysteroscopy, by the Versapoint 5 Fr. procedure. These included 445 endometrial polyps, 49 submucosal myomas <2 cm and 21 partial intramural myomas with a submucosal section <1.5 cm. Larger myomas were treated with the resectoscope, as in our experience use of the 5Fr. Versapoint electrodes to treat these larger myomas (>2 cm) is time-consuming and yields lower quality final results. The patients came to our centre for abnormal uterine bleeding, abnormal ultrasound findings, sterility/infertility problems and evaluation prior to or during hormone replacement therapy (HRT). They underwent an office hysteroscopic procedure, without any analgesic pretreatment, in the proliferative phase of the cycle (days 611) as well as transvaginal ultrasound (TVUS). Infertile patients presenting a partially intramural myoma (n = 21) were pretreated with 3 months of GnRH analogue to shrink the fibroids. In all cases the removed tissue was sent to a pathologist for histological confirmation.
To verify patient acceptability, a visual analogue score of pain was proposed immediately after the procedure (Downes and Al-Azzawi; 1993). Patients were asked to complete privately an anonymous questionnaire assessing the maximum amount of pain suffered during the procedure, by marking a cross on a 10 cm line. The following classification was proposed: 01 = no discomfort; 24 = discomfort similar to normal menstrual pain; 57 = moderate pain similar to heavy menstrual pain; 810 = severe pain.
Operative technique
All polyps <0.5 cm were removed using 5 Fr. mechanical instruments (sharp scissors and/or crocodile forceps), largely for cost reasons. Larger polyps were removed intact, with the Versapoint Twizzle electrode, only if the internal cervical os size was wide enough for their extraction. Otherwise, they were sliced from the free edge to the base into two/three fragments large enough to be pulled out through the uterine cavity using 5 Fr. grasping forceps with teeth (Figure 2). To remove the entire base of the polyp without going too deep into the myometrium, in some cases the Twizzle electrode was bent by 2530°, enough to obtain a kind of hook electrode. A similar technique was applied on submucosal myomas with the difference that, due to their higher tissue density, they were first divided into two half-spheres and then each of these was sliced as described above (Figure 3
). Particular attention was paid to the intramural part of the myoma, if present. To avoid any myometrial stimulation or damage, the myoma was first gently separated from the capsule using mechanical instruments (grasping forceps or scissors) as already described for resectoscopic myomectomy (Mazzon and Sbiroli, 1997
; Gimpelson, 2000
). Once the intramural section became submucosal it was sliced with the Versapoint Twizzle electrode. Unpaired Students t-test was used for statistical analysis; P < 0.05 was considered statistically significant.
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Results |
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The 49 submucosal myomas ranged between 0.52.0 cm and the average operating time was 22 min (longer due to the need to slice the myoma at different angles prior to removal, as discussed above). The 21 partially intramural myomas, all pretreated with 3 months of GnRH analogue therapy, ranged between 0.61.5 cm and the average operating time was 31 min (still longer due to the special operative techniquea combination of mechanical and electrical instruments, as described aboveand to the need to avoid any myometrial stimulation, particularly difficult in view of the location of the myoma). The results of the visual analogue scale assessing patient discomfort are reported in Table I.
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Histological examination of the removed tissue showed a correspondence with the hysteroscopic diagnosis in all cases but one. This was a menopausal patient taking HRT who presented with abnormal uterine bleeding. TVUS showed an endometrial thickness of 7 mm. At hysteroscopy, a 1.5 cm polyp on the anterior uterine wall was discovered and removed during the same procedure. The macroscopic aspect at hysteroscopy was normal, without any sign of necrosis, degeneration or vascular abnormalities, but histology showed a focal carcinoma located at the base of the polyp. The patient underwent hysterectomy 2 weeks later and the final histological examination of the whole uterus showed no sign of malignancy.
No failures or major complications (i.e. severe pain, vagal reflex, intravasation, uterine perforation, etc.) occurred during the procedures.
Follow-up was performed after 3 months, or after two spontaneous cycles in patients who had had GnRH pretreatment (n = 21). All the hysteroscopic procedures were performed during the proliferative phase of the cycle (days 611) to avoid endometrial thickness. Only one patient underwent hysterectomy, as described above. No recurrence of the pathologies was observed at follow-up in any of the patients. In those operated upon for myomas, the uterine wall had a normal aspect with no scar tissue.
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Discussion |
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In conclusion, improved technology now enables us to perform many operative procedures in an office setting, without significant patient discomfort, reserving operating room hysteroscopy (resectoscopy) for the treatment of the less common, larger intrauterine pathologies.
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Notes |
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References |
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Submitted on January 30, 2002; resubmitted on April 3, 2002; accepted on May 13, 2002.