Hysteroscopy in daily practice
Dongen, H. van
Citation
Dongen, H. van. (2009, February 26). Hysteroscopy in daily practice.
Retrieved from https://hdl.handle.net/1887/13533
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Chapter 1
General introduction
Chapter 1 10
The first instrument intended to illuminate the cavities of the human body was invented by Phillip Bozzini, who was born more than 200 years ago (1773-1809). Unfortunately, Bozzini’s Lichtleiter became a victim of the absolutistic world of the early nineteenth century; his ingenious invention was discounted as mere toy. Interestingly, Bozzini once replied to a negative report on one of his inventions “It means nothing for an invention when somebody gives a judgment based only on his own authority and not on his own experiments and clinical experience” [Rathert 1974]. In modern times a similar attitude may be observed. Innovations in endoscopic technology proceed at such a speed that a thorough evaluation takes longer than the development of more advanced techniques.
This leads to the use of instruments and procedures based upon little evidence.
After Bozzini’s invention of the Lichtleiter in 1807, the first successful hysteroscopy was reported by Pantaleoni in 1869 [Pantaleoni 1869]. He examined the uterine cavity of a 60-year-old woman with postmenopausal bleeding, and found an intrauterine polyp, which he managed to cauterise with silver nitrate. So this was not only the first diagnostic hysteroscopy, but the first known case of intrauterine surgery as well. After this nineteenth century achievement, however, the development of hysteroscopy, in contrast for example to cystoscopy, proceeded slowly. This was largely imputed to technically limiting imaging (e.g. lack of distension of the uterine cavity and blurred vision by bleeding) and a relative inability to treat encountered pathology. It was not until the last third of the twentieth century that changes in light source, endoscopic design, and creative use of distend- ing media established an effective platform for the development of several therapeutic applications.
In the past, the established method for examining women with abnormal uterine bleed- ing was dilatation and curettage, which was found to sample only half of the available endometrium [Stock 1975]. Gimpelson et al. proved that hysteroscopic examination of the uterus was more accurate than dilatation and curettage, whereupon diagnostic hys- teroscopy with or without endometrial sampling was suggested [Gimpelson 1988].
Traditionally, diagnostic hysteroscopy was performed in an inpatient setting with anaes- thesia, but a series of refinements improved the tolerability of the procedure and made it possible to perform it in an outpatient setting with or without local anaesthesia.
Nowadays, a diagnostic hysteroscope consists of an optical telescope with a diameter of about 2-4mm, surrounded by a sheath which allows for the circulation of a distension medium and increases the total diameter to 4-6mm.
Distension of the uterus is necessary for visual inspection of the uterine cavity. This can be achieved by local instillation of normal saline. Compared to CO2-gas, this proved more comfortable for the patient, and provides a superior view, especially in cases of bleed- ing [Shankar 2004]. Recently, a vaginoscopic approach to hysteroscopy was introduced.
It eliminates the need to introduce a vaginal speculum and tenaculum to expose and grasp the cervix, and is thought to reduce discomfort in patients [Bettocchi 1997]. For
General introduction 11
this approach rigid hysteroscopes are required. These scopes give an undistorted image that is as clear at the periphery as at the centre. Flexible scopes, on the contrary, produce a rather grainy view due to the flexible nature of the optical fibres and are considerably more expensive.
Nowadays hysteroscopic surgery includes the removal of intrauterine devices (IUD’s), the removal of endometrial polyps and submucous myomas, endometrial ablation, metro- plasty in cases of congenital abnormalities, the removal of retained products of concep- tion, adhesiolysis and tubal sterilisation. Hysteroscopes most commonly used for intra- uterine surgery have an outer sheath of 8-9mm diameter, requiring cervical dilatation and therefore regional or general anaesthesia and an operating theatre. To allow optimal visibility irrigation fluid is circulated rapidly rinsing the uterine cavity of blood and tissue debris. Surgery can be performed with various instruments including scissors, forceps and electrodes. The use of monopolar electrodes requires non-conducting distension media (e.g. glycine, sorbitol or mannitol), and excessive intravasation of this type of distension fluid can be life-threatening [Vulgaropulos 1992]. Bipolar electrodes allow normal saline as a distending medium, thereby improving the patients’ safety [Kung 1999].
Furthermore, since hysteroscopes with a final outer diameter sheath of 5mm or less have enabled performance of diagnostic hysteroscopy in an outpatient setting, small mechani- cal instruments (e.g. grasping forceps or scissors) and bipolar electrosurgical technology have allowed for hysteroscopic procedures to be performed in an ambulatory setting as well. This primarily includes the removal of IUDs, small intrauterine lesions (e.g. polyps, small submucous myomas and adhesions) and hysteroscopic tubal sterilisation.
The introduction of hysteroscopic surgery has changed the surgical landscape from one previously dominated by hysterectomy to a surgical field containing a plethora of less invasive procedures that allow for uterine preservation, as well as reduced procedural and postoperative morbidity. These options have clear benefits for patients but challenges for gynaecologic surgeons. With the continuous rapid development of new diagnostic and therapeutic procedures surgeons must now critically evaluate the role of these tech- niques in daily practice.
The questions to be addressed in this thesis against this background are:
• Implementation of hysteroscopy – How has the practice of hysteroscopy evolved in medical care in The Netherlands?
• Diagnostic hysteroscopy – How accurate is the procedure at diagnosing pathology and how well is it tolerated by patients?
• Hysteroscopic surgery – How effective is removing intrauterine pathology in improv- ing patients’ symptoms? What are the implications of hysteroscopic surgery on the practice of hysterectomy?
Chapter 1 12
Outline of the thesis
Implementation of hysteroscopy
The diffusion of hysteroscopic surgery in The Netherlands in general is discussed in chap- ter 2, while chapter 3 deals with more detailed implementation matters at the level of skills training.
When focussing on the skills, a new hysteroscopic morcellator was suggested easier to master than the electrosurgical resection technique particularly for the removal of polyps and submucous myomas [Emanuel 2005]. For this reason, both techniques were com- pared among residents in training and discussed in chapter 4.
Diagnostic hysteroscopy
Since Gimpelson and Rappold [Gimpelson 1988] reported that hysteroscopy was more accurate than dilatation and curettage, diagnostic hysteroscopy has been suggested as the method of choice in the evaluation of the uterine cavity. A systematic review and a meta- analysis evaluating this assumption among patients with abnormal uterine bleeding are described in chapter 5.
A previously performed systematic review on saline infusion sonography showed that its diagnostic accuracy is as good as that of hysteroscopy [de Kroon 2003a]. Additionally, saline infusion sonography demonstrated to be less painful than hysteroscopy [Rogerson 2002; Widrich 1996]. Though, this evidence dates from a time in which hysteroscopy was performed with scopes of a larger diameter, a speculum and a tenaculum. The vaginoscopic approach used nowadays has reduced discomfort considerably [Bettocchi 1997], therefore in chapter 6 patient pain scores of saline infusion sonography and vagi- noscopic hysteroscopy are compared. Since hysteroscopy has a certain advantage over saline infusion sonography with regard to treatment, the patients’ preference is evaluated in chapter 7.
Hysteroscopic surgery
A number of hysteroscopic procedures (e.g. the removal of myomas and endometrial abla- tion) are considered attractive alternatives to hysterectomy because they reduce the length of the hospital stay and the morbidity rate. A variety of these applications are discussed in the following chapters. Chapter 8 is concerned with the intervention-free time follow- ing the incomplete removal of submucous myomas. In chapter 9 the amount of monthly blood loss in premenopausal patients with endometrial polyps is objectified before and shortly after hysteroscopic polypectomy. In addition, the intervention-free time on the long term of premenopausal patients with abnormal uterine bleeding who underwent hysteroscopic polyp removal is detailed in chapter 10. Whether the introduction of these therapies substantially reduces the need for hysterectomy is assessed in chapter 11.
Finally, the results of this thesis are discussed in chapter 12, clinical recommendations are given in chapter 13, and a summary (in English and Dutch) is provided in chapter 14.
