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Hysteroscopy Newsletter Vol 6 Issue 6 English
Hysteroscopy Newsletter Vol 6 Issue 6 English
Vol 6 Issue 6
Editorial
José Carugo
HYSTEROSCOPY
Editorial teaM
TEAM COODINATORS
L. Alonso
J. Carugno
EDITORIAL COMMITTEE
SPAIN Looking back to move forward
E. Cayuela
L. Nieto Dear hysteroscopy friends,
ITALY The year 2020 is coming to an end. As we look back with disbelieved and a great
G. Gubbini deal of disappointment, sadness and sorrow, we need to stay stronger than ever as
A. S. Laganà we see this terrible COVID-19 pandemic continue to spread around the word and
not wanting to leave. It has had catastrophic consequences at all levels. Starting
USA from the thousands of people who have lost their lives succumbing to this terrible
L. Bradley infection, including many physicians standing at the front line, the devastating hit on
the economy, the psychologic impact that is having on all of us, the consequences
MEXICO of social distancing measures. When comparing 2020 to any of the previous years,
J. Alanis-Fuentes I can’t avoid missing what we can now call “the good all days”. Those multiple
scientific meetings in which we used to share our knowledge, have some drinks,
BRASIL
enjoy good food and take a couple of selfies with the professors. The crowded
Thiago Guazzelli
“auditorium” full of people waiting for the meeting to start, multiple friends from all
ARGENTINA over the word sharing their knowledge and eager to learn. But, all that, for the better
A. M. Gonzalez or worse will only live in our memory.
VENEZUELA My dear friend, believe me, not all is bad. With difficult times good things happen.
J. Jimenez It is well known that during big crisis 2 things always happen (we have learned this
from the past, such as after the 9/11 terrorist attack). The first is altruism, people
start being nicer to each other, we help each other more and work together to
achieve the same goal, and the second is innovation. I can safely attest that the
SCIENTIFIC scientific innovation of the year, as we wait for the COVID-19 vaccine, is the
COMMITTEE “Webinar”. All our scientific activities, meetings and gatherings move to the screen
of our laptop, tablet or cell phone. We now only have to look back to move forward
A. Tinelli (Ita) facing “the new normal”.
O. Shawki (Egy)
A. Úbeda (Spa) The hysteroscopy newsletter will also innovate and adapt to the new normal. We
A. Arias (Ven) have been with all of you over the last 6 years and we really appreciate the support
A. Di Spiezio Sardo (Ita) of each one of you who have provided interesting articles and beautiful pictures,
E. de la Blanca (Spa) and to the readers that always gave us great feedbacks. Facing the new normal,
A. Favilli (Ita) Hysteroscopy Newsletter will now become more digital, with less words and more
M. Bigozzi (Arg) pictures and videos. We will take advantage of the social media platforms and will
S. Haimovich (Spa) have the opportunity to reach all of you with the same enthusiasm that we have
E. Xia (Cn) done it over the last 6 years. Hysteroscopy Newsletter will now be “Quarterly”. Will
R. Lasmar (Bra) have 4 issues/year loaded with videos, photos and up to date information about
what is happening in the world of hysteroscopy. As we stand strong looking forward
A. Garcia (USA)
with great stoicism, we are preparing for the “new normal” with more enthusiasm
J. Dotto (Arg)
and energy than before. As always, we count on you to continue supporting the
R. Manchanda (Ind)
“Hysteroscopy Newsletter” as you have done it over the last 6 years. Will always
M. Medvediev (Ukr)
stay strong together looking forward to a great future.
M. Elessawy (Ger)
X. Xiang (Cn)
Stay safe,
G. Stamenov (Bul)
Peter Török (Hun)
Jose “Tony” Carugno
All rights reserved.
The responsibility of the signed contributions is
primarily of the authors and does not If you are interested in sharing your cases or have a hysteroscopy image that
necessarily reflect the views of the editorial or
scientific committees. you consider unique and want to share, send it to hysteronews@gmail.com
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The main goal during in office diagnostic Rapid uterine relaxation is another the cause of
hysteroscopy is to obtain a smooth access the pain. It is advisable not to use high intrauterine
uterine cavity, making a full assessment, in a way pressure, reducing the in-flow of distention media
that the patient can tolerate the procedure with at the beginning of the procedure. If the distention
minimal discomfort. Here we will describe common media enter the cavity too fast (high pressure), or if
everyday situations and provide some tips to we have to release adhesions to enter the cavity it
improve your skills. will cause pain. It is desirable to distend the cavity
gradually. This is achieved by regulating in-flow of
distention media.
What is the best tolerated uterine access
technique?
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When in presence of a marked anteflexed uterus, Evaluating the uterine shape and size is an
we find it difficult to access cavity with a rigid important part of diagnostic hysteroscopy. It is
hysteroscope. A simple way to correct this angle really important to be systematic in the
and access cavity is to have an assistant apply assessment,especially in cases where we find
light suprapubic pressure to improve the angle of intracavitary pathology. We must be rigorous in
the uterus and cervical canal facilitating the assessing the endometrium, as behind a polyp or
insertion of the hysteroscope. fibroids can hide endometrial pathology. Therefore,
before performing any procedure, such as taking
Access to the cavity biopsy or resect a polyp or fibroid, it is
recommended to assess the entire endometrium.
Before we begin to evaluate the cavity, we must
always ask ourselves, where the tip of the How to properly take a biopsy and perform
hysteroscope is? That is achieved by slightly tissue extraction?
withdrawing the hysteroscope to get an overall
view. The best point of reference in the uterine Taking an adequate biopsy prevent the need of
cavity is visualization of the tubal ostium, especially multiple insertions of the hysteroscope causing
in cases where the uterine cavity has abnormal unnecessary discomfort to the patient. The biopsy
shape or access has been difficult. grasper must move en bloc along with the
hysteroscope, without working at excessive
distance from the tip of the hysteroscope, not to
loose strength or definition when performing a
direct biopsy. To get more biopsy tissue and avoid
loosing the specimen when removing the
hysteroscope through the cervical canal, when
taking the biopsy do not obtain a pinch of tissue
but place the specimen inside the open biopsy
clamp and advance the clamp into the tissue as
you close its jaws, ensuring a greater amount of
tissue within the clamp.
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The rapid advance of technology and the The uterine approach by vaginoscopy first
miniaturization of hysteroscopes has allowed an described in 1995 by Bettocchi and Selvaggi (1)
easier and painless access to the uterine cavity. As avoids both the use of the speculum and
a result, the number of interventions carried out in tenaculum to grab the uterine cervix, an obvious
the office setting, and outside the operating room, way to reduce the discomfort experienced by the
is increasing in a rapid manner. patient. This technique consist of direct
introduction of the hysteroscope in the vagina,
However, failed access to the uterine cavity, getting the expantion of the vaginal walls by fluid
either due to cervical stenosis or pain, remains the distention with normal saline. This separation of
leading cause of inability to perform in office the vaginal walls allows to locate the EO
hysteroscopy. This chapter will discuss different introducing the hysteroscope, and then continue
strategies to facilitate the access through the through the cervical canal.
uterine cervical canal.
TECHNICAL ASPECTS
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Scrolling through the cervical canal The use of prostaglandins before hysteroscopy
facilitates cervical dilation, lower the possibility of
Progress through the cervical canal should be complications such as cervical laceration,
done with a clear and comprehensive vision of the decreases consistency and resistance of the cervix
entire canal and following the angle that this and reduces pain during the performance of
presents. The orientation of the longitudinal crests hysteroscopy. (6) Misoprostol, a synthetic
“plica palmatae” guide us the way to the IO. analogue of prostaglandin E1 (PGE1) is the most
commonly used prostaglandin for cervical
The technique varies according to the angle of preparation due to its effectiveness, low cost and
the optics utilized (0º-12º-30º) the main aspect of availability. These benefits are clear in
this technique is to advance the hysteroscope premenopausal patients while they are not proven
through the middle of the cervical canal, avoiding in postmenopausal or in patients receiving GnRH
collision with the side walls. Perhaps the most analogues. Although, in a recent study, Oppegaard
difficult area encountered when using this et al observed that after 14 days of pretreatment
technique is at the level of the IO where there is a with vaginal estradiol, the administration of
fibromuscular area that narrows the final access to misoprostol has a significant effect on cervical
the uterine cavity. ripening prior to hysteroscopy in postmenopausal
patients. (7)
SPECIAL MEASURES
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Different anesthetic that can be applied on the It consists of the injection of the anesthetic directly
cervix to decrease pain during hysteroscopy are into the cervical tissue. Usually infiltration takes
the paracervical block, intracervical inyection and place in the quarters, inyecting a total of 5 ml each
topical anesthesia. The paracervical block puncture to a depth of 10 mm. As in the
anesthesia is the only one that has proven to be paracervical anesthesia, 1% lidocaine with
effective in decreasing pain perception, while epinephrine is the most commonly used
topical anesthesia has no significant effect on pain. anesthetic. There is conflicting evidence regarding
the efficacy of this route of administration,
generating doubts about the decrease of pain
perceived by the patient.
SPECIAL SITUATIONS
Cervical stenosis
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Rigid optics have a bevel tip, which gives the In certain situations, we face a real cervical
capacity for tissue penetration and ability to disintegration in which we are unable to identify any
separate the fibers. Most cases of cervical stenosis recognizable structure and, of course, it is
are solved by a rotational movement of the tip of impossible to determine where the external os is
hysteroscope to separate the fibrous tissue and located. Cervical disintegration often occurs in
allow to advance of the hysteroscope. patients with history of invasive surgical procedures
on the cervix such as traquelectomy or cold knife
Mechanical entry conization. In these patients access to the cervix
represents a challenge and the use of ultrasound
The use of biopsy forceps or hysteroscopic guide or cold cervical incision with a scalpel often
scissors help to overcome more severe cases that allows access to the unstructured cervix. There are
are not solved by the input optical rotation some case report describing hysteroscopic uterine
technique. The introduction of scissors or a closed access in patients with unstructured cervix. Shankar
clamp into the stenotic cervical canal and et al. reported a case of a 65 year old patient with
subsequent opened extraction, dilate the cervix postmenopausal bleeding in whom a cut of 15 mm
just enough to introduce the tip of the performed with a cold knife was performed to
hysteroscope. Sometimes the use of scissors is introduce the hysteroscope into the uterine cavity.
needed to cut the lateral corner of the cervical
canal or fibrous tissue adhesions at the level of the Overcoming cervical stenosis in office hysteroscopy
internal os. is challenging and often requires to abort the
procedure and to take the patient to the operating
Entrance with bipolar electrode room for treatment under general anesthesia.
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The first time I touched the magic of office First I must mention all-in-one systems. They have
hysteroscopy was during a workshop in Bulgaria in integrated camera, light, monitor and recording
2010, when Prof. Stefano Bettocchi came and system in one, and some are really small in size. An
performed several demonstrational operations. It was example for that is EndoSee by Cooper Surgical. In
really amazing how in a few minutes he solved some fact it is an excellent device, which was available in
difficult cases, which even after 2 or 3 curettages did few European countries. It has disposable working
not have the right diagnosis. And all this was without part, which can be changed for every patient.
anesthesia, without any medication, without masks… Disadvantage of EndoSee is the absence of a
working channel. You cannot take even a small
When I asked “How can I make that?”, the company biopsy, which will be your desire after a few
representative told me “It is not so difficult or procedures. So you will like to change it quickly.
expensive! We will arrange you a good set for 30,000
euro.” It would be quite an investment for me, as I
was a resident. And at that moment I wondered how I
could make it more accessible for more doctors,
especially beginners, as I was. Because when you
want to learn driving a car, you do not make it on a
Lamborghini or a Ferrari, but on your daddy’s old car
or a small self- bought one.
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Hysteroscope is really crucial for the successful All of these systems have their advantages and
office practice. There are a lot of systems on the disadvantages, but you must know them when you
market, but I think you have to keep in mind 2 try to choose the perfect one for your practice. It is
magic words – oval shape and less than 5.5 mm. not necessary to discover the hot water, just ask
Oval shape of the sheath is anatomically the experts during workshops and congresses or
acceptable and causes less pain. You can use it as even on discussion groups in Internet, everyone
a screw during the procedure and dilate the will share its experience and you will have enough
cervical canal in nulliparous or postmenopausal information to take the right decision.
women. About the 5.5 mm – that is the cut-off of
painless hysteroscope diameter. You can use In brief I can summarize that everything depends
Versascope with fiber optical 1.8 mm semi rigid on what you want and what kind of procedures you
body, with single use sheath with total diameter 3.2 plan to perform, taking into account the number of
mm. Or old Bettocchi system with 2.9 mm optics patients and the type of financing /healthcare
without outer sheath with total diameter of 4.2 mm. insurance, selfpayment/. All information discussed
Or the new BIOH hysteroscope with small above is according to author’s personal
diameter, which cannot give you the inflow and experience. Probably there are so many other
outflow at the same time. Built-in Compact Office good devices and equipment, and every doctor can
Hysteroscope of Richard Wolf has all advantages find the best solution for himself. But the idea is
of office hysteroscopes. The only important thing to that you need to face your desires what you want
count in the two last hysteroscopes is that after to do, to discuss your wishes with more people and
every procedure the system must be sterilized. If experienced colleagues and accordingly to build
your practice is too busy, but you plan to have your own “best office hysteroscopy system”.
mainly diagnostic procedures even a single use
Gynko of MedicalSwan Italia sheath on 2.9 mm 30
or 0 degrees hysteroscope, with total diameter of
3.2 mm and working channel for 7 FR instrument is
a solution. Just attention must be paid to the fact
that the small diameter of Gynco cannot protect
fully the optics which could cause damage to it
during procedure. And if a bleeding occurs the
visualization of the cavity is worse.
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Hysteroscopic surgical techniques have the scope and hydrodistension is ideal. If cervical
advanced to include more endometrial ablation dilation is needed, it is important to only dilate the
devices, bipolar electrosurgery, hysteroscopic cervix and not advance the dilator all the way
sterilization, and morcellators. As residents to the fundus to avoid perforation and trauma to
complete simulation training programs and learn to the endometrial cavity that will affect visualization.
become hysteroscopic surgeons, it is important to Often in postmenopausal patients, the uterine
follow safety tips at each step of the surgery. depth will be small, and perforation could even
Hysteroscopy procedures involve the introduction occur during dilation.
of instruments into the uterus and distention with
fluid media.
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5. In order to avoid air embolism, preventative 2500 mL is acceptable in a young healthy patient,
strategies including flushing air from tubing and but is 1000 mL for hypotonic solution such as
making sure that the procedure is stopped and glycine. The fluid deficit should be limited in older
tubing is purged of air when bags are changed. In patients or patients with heart failure or renal
addition the patient should not be placed in the insufficiency.
Trendelenburg position during cervical dilation or
during the procedure in order to avoid a suction
that may draw air into the uterine cavity. If there is 9. A preoperative pelvic exam should be
a sudden cardiovascular collapse immediate completed by the clinician to determine uterine
management should be initiated for an air or CO2 position. Ultrasound guidance may be useful to
emboli. avoid uterine perforation. If the hysteroscope is
inserted and the uterus is unable to be distended
at any point during the procedure it is possible
6. Care should be taken while inserting the there is a uterine perforation. At this point the case
hysteroscope into the uterine cavity to assure that should be stopped and reassessed. Laparoscopy
a false tract in the cervical canal has not been may be needed and useful to determine the extent
made. If one proceeds to close to the depth of of damage.
sounding without visualization of the cavity this
should be considered, with re-attempts to gain
entry into the uterine cavity. 10. It is important that if any new devices are used
for hysteroscopy that the entire surgical team has
been trained and is aware of their use ahead of
7. Hemorrhage may occur during hysteroscopic time. This could include new morcellators or
surgery and can be controlled with electrosurgical electrosurgical devices.
coagulation if the bleeding site can be visualized.
Other strategies include injection of vasopressin
into the cervical stroma or Foley catheter balloon If one follows these general safety tips and
tamponade. consideration it will ensure an emphasis on patient
safety and continuous audit of new techniques or
technologies. Remember it is always appropriate to
8. Monitor fluid intake to avoid fluid overload. select cases carefully and practice using
Complications may be prevented by limiting simulation. There should be patient and surgical
excess fluid absorption, keeping track of ins and team preparation before entering the operating
outs, and selecting a distending medium such as room. One should be familiar with the equipment
saline that minimizes risks in healthy patient's and distention media in order to maximize patient
using isotonic solutions. A maximal fluid deficit of care.
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Additionally, to decreasing of scopes caliber there visualization and need of removal of resected
are new mechanical and bipolar instruments been fragments resulting in a time-consuming
developed these days. Some data showed high procedure, thermal damage to endometrium with
efficacy and tolerability of new instruments for out- permanent detrimental effects on future fertility and
patient operative hysteroscopy. In one study the relatively long learning curve, remain still unsolved.
outpatient polypectomy was associated with a Invention of mechanical hysteroscopic morcellators
success rate of 95%. has made a great improvement in management
polyps and myomas. Hysteroscopic morcellator
Other outcomes such as discomfort after the was developed to reduce problems mentioned
procedure, time away from home, analgesia above and decrease an operative time comparing
requirements, description and satisfaction of the with traditional approach. Hysteroscopic
procedure were all in favour of the outpatient mechanical morcellation allows removal of the
setting. Further, patients in the outpatient group tissue automatically during hysteroscopic resection
recovered faster [12]. and leads to a reduced operating time. There is
evidence that the learning curve for use of the
Recently even more portable devices of office hysteroscopic morcellator is shorter than for
hysteroscopy have been introduced to the market. conventional monopolar resectoscope in relative
One of these is EndoSee device (CooperSurgical, novices [11].
Trumbull, CT, USA). The Endosee Hysteroscope is
a lightweight, handheld, battery operated portable Hysteroscopy has become an important tool to
system. It is used with a single-use Disposable evaluate intrauterine pathology including
Diagnostic (Dx) Cannula with a camera and light endometrial polyp, submucous myoma, intrauterine
source at the distal end to illuminate the area for adhesions and uterine anomaly. In most cases, the
visualization and image and video capture. The diagnosis and treatment of these lesions can be
video signal is electronically transferred to the main performed in the office or outpatient setting without
body of the hysteroscope via an electrical need for anesthesia. Smaller, more portable
connector. An LCD touch screen display monitor systems are now able to provide good views and
on the hysteroscope is used for viewing [1]. with image storage facilities. As a consequence, a
single room can be used for various purposes,
providing more opportunity for the development of
outpatient facilities for ambulatory gynecology.
1.Connor, M., N ew t e chnologie s and innovat ions in hys t e roscopy. Best Pract Res Clin Obstet
Gynaecol, 2015. 29(7): p. 951-65.
2.Siegle, A.M., T he e arly hist ory of hyst e roscopy. J Am Assoc Gynecol Laparosc, 1998. 5(4): p.
329-32.
3.Kogan, L., et al., Ope rat ive hyst e ros copy f or t re at me nt of int raut e rine pat hologie s doe s
not int e rf ere wit h lat e r e ndome t rial de ve lopme nt in pat ie nt s unde rgoing in vit ro
f e rt iliz at ion. Arch
Gynecol Obstet, 2016. 293(5): p. 1097-100.
4.Bettocchi, S. and L. Selvaggi, A vaginoscopic approach t o re duce t he pain of of f ice
hyst e ros copy. J Am Assoc Gynecol Laparosc, 1997. 4(2): p. 255-8.
5.Cooper, N.A., et al., Vaginoscopic approach t o out pat ie nt hyst e roscopy: a s yst e mat ic
Fig. 3. Intrauterine BIGATTI Shaver, Karl Storz revie w of t he e f f e ct on pain. BJOG, 2010. 117(5): p. 532-9.
6.Lin, B.L., et al., T he Fuj inon diagnost ic f ibe r opt ic hyst e roscope . Ex pe rience wit h 1,50 3
pat ient s. J Reprod Med, 1990. 35(7): p. 685-9.
7.Bettocchi, S., et al., A dvanced ope rat ive of f ice hys t e roscopy wit hout anaes t hes ia: analys is
of 50 1 cas es t re at e d wit h a 5 Fr. bipolar e lect rode . Hum Reprod, 2002. 17(9): p. 2435-8.
At present, conventional hysteroscopic resection 8.Marciniak, A., et al., [Role of of f ice hyst e roscopy in t he diagnos is and t re at me nt of
ut e rine pat hology]. Pol Merkur Lekarski, 2015. 39(232): p. 251-3.
can be considered the gold standard procedure for 9.Campo, R., et al., Of f ice mini-hyst e ros copy. Hum Reprod Update, 1999. 5(1): p. 73-81.
major hysteroscopic operations. Despite well- 10.Di Spiezio Sardo, A., et al., A mbulat ory manageme nt of he avy menst rual ble e ding. Womens
Health (Lond), 2016. 12(1): p. 35-43.
recognized advantages of resection, several 11.Closon, F. and T. Tulandi, Fut ure re se arch and de ve lopment s in hys t e roscopy. Best Pract
problems, such as fluid overload , uterine Res Clin Obstet Gynaecol, 2015. 29(7): p. 994-1000.
12.Marsh, F.A., L.J. Rogerson, and S.R. Duffy, A randomise d cont rolle d t rial comparing
perforation due to electric current, lack of out pat ient ve rsus daycase e ndome t rial polype ct omy. BJOG, 2006. 113(8): p. 896-901.
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