Juniper Publishers: Small Diameter Hysteroscopy: Is it a Real Opportunity?
JUNIPER PUBLISHERS- JOURNAL OF GYNECOLOGY AND WOMEN’S
HEALTH
Journal of Gynecology and Women’s Health-Juniper
Publishers]
Authored by Enrico Michelino Messalli*
Abstract
The hysteroscopy is the gold standard for treatment
of uterine intracavitary diseases. It is effective and safe with low
rate of recurrence and complications. The features of intrauterine
lesions are factors influencing the instrument choice. The larger are
generally treated by resectoscope but this technique is associated with
potential serious complications mainly due to the need of cervical
dilatation. To overcome this limitation, technological improvements have
led to the introduction of small-diameter hysteroscopes not exceeding
5mm in diameter equipped with bipolar electrodes that
work in saline solution. The vaginoscopic approach avoids the use of
speculum and tenaculum, and the small caliber of the instruments avoids
cervical dilatation; therefore small-diameter hysteroscopes are more
suitable. However, the major challenge in the use of small diameter
hysteroscopy is the extraction of tissue fragments through a narrow
cervical canal. Therefore, hysteroscopic morcellation is introduced. It
provides a fast, effective and safe alternative to bipolar resectoscopy
in the hysteroscopic treatment of endometrial polyps, but future trials
are required for assess cost-effectiveness and cost-benefit ratio. To
date, there are no guidelines defining the limits of the size, location
and number beyond which small diameter hysteroscopy should be preferred
to the resectoscopy. However, the indications for small-diameter
operative hysteroscopy are expanding and not yet completely defined; in
experienced hands a small-diameter hysteroscopy is a safe and effective
approach for benign endometrial disease up to 4cm, especially in
patients with unfavourable cervical canal at risk of cervical injury.
Keywords: diameter; Hysteroscopy; Resectoscope; Hysteroscopic morcellationIntroduction
The hysteroscopic approach is the gold standard for
treatment of uterine intracavitary benign diseases because it is
effective and safe with low rate of recurrence and complications [1,2].
The size, shape and location of adhesions, septa,
polyps and/or myomas are factors influencing the instrument choice. The
larger benign lesions are generally treated by resectoscope equipped
with monopolar or bipolar knife [3].
When compared to monopolar, bipolar resectoscopy reduces the risk of
electrolyte disturbances and burns; for these reasons, it is the
preferred method [4,5].
Despite the excellent results, the resectoscopic
technique may be associated with serious complications due to the need
of cervical dilatation in addition to thermal injuries or fluid
intravasation [6,7].
In fact, most of the complications are related to cervical dilatation
and not to the specific hysteroscopic procedures, regardless of the
surgeons’ experience [8].
Nulliparity, postmenopausal state, stenosis of cervical canal, postmenopausal small cervix [9],
previous surgery on the cervix and previous cesarean sections are all
conditions able to make difficult to dilate the cervical canal
increasing the risk of traumatic lesions (cervical trauma, false track,
uterine perforation) [10,11].
Other strategies to avoid cervical injury include the
use of laminaria japonica and vaginal prostaglandins. However, the
evidence is unclear as to whether the dilatory effect of prostaglandins
is apparent in a nonpregnant cervix; moreover, any potential benefit
must to be weighed against unpleasant adverse effects (nausea, vomiting
and excessive bleeding) and the costs associated with prostaglandin use [10].
Currently, there is insufficient evidence to recommend their routine
use preoperatively in outpatient hysteroscopy. Cervical priming with
vaginal prostaglandins may be considered in selected postmenopausal
women if using hysteroscopic systems >5mm in diameter [10,12].
Discussion
Technological improvements have led to the
introduction of small-diameter hysteroscopes not exceeding 5 mm in
diameter equipped with bipolar electrodes that work in saline solution.
They allow a simple and safe treatment of many intrauterine diseases,
reducing the risk of severe complications [13,14].
In fact, the vaginoscopic approach avoids the use of speculum and
tenaculum, and the small caliber of the instruments avoids cervical
dilatation; therefore small-diameter hysteroscopes are more suitable for
patients with “unfavorable” cervix [11].
The small diameter hysteroscopy can play a key role
in the diagnosis and treatment of relatively common lesion of low
genital tract in children and adolescents [15].
The vaginal examination of these patients necessitates the use of a
pediatric speculum, an instrument that is relatively traumatic and can
cause erosions or lacerations to the hymen and vaginal walls [16].
The difficulty in performing a gynaecological examination in a child
(even under anaesthesia) may delay diagnosis and treatment. The
evaluation of the lower genital tract using a small diameter
hysteroscope is, therefore, an ideal option by enabling good inspection
of the vaginal walls and cervix without trauma to the genital structures
[15].
The employment of mini hysteroscopes and vaginoscopic
approach has been developed to improve feasibility and reduce pain and
side effects allowing a wide spread of the outpatient hysteroscopy. The
reduction in the size of the instrument is of great importance for
reducing pain and risk of vasovagal reactions [17].
Several studies confirmed that pain and vasovagal reactions were
significantly lower with the minihysteroscope compared with the standard
[18-20].
However, the major challenge in the use of small
diameter hysteroscopy is the extraction of tissue fragments through a
narrow cervical canal. To overcome this limitation preserving the small
diameter of instrument in 2005 an alternative to resectoscopyis
marketed: hysteroscopic morcellation [21].
This mechanical technique combines cutting and aspiration, using saline
as continuous flow irrigation solution. Possible benefits in comparison
with bipolar resectoscopy are: reduction of operative time;
mechanically cut of tissue without lateral electrical damage; no gas
bubbles arising upon activation of the device, resulting in better
vision and reduced risk of complications such as gas embolism [22];
continuous aspiration of the tissue fragments by hysteroscopic
morcellation ensuring a clear view and an immediately collection of
tissue for histological examination [3]. However, there are also disadvantages, such us the inability to coagulate bleeding vessels [23]
or the cost of the disposables (blades, tubings) needed to perform
hysteroscopic morcellation, that is higher compared with the reusable
instruments for resectoscopy [3].
Hysteroscopic morcellation may, however, diminish the
risk of (re)introduction related perforation, as a result of immediate
tissue removal, with less hysteroscope reinsertions [3].
Hysteroscopic morcellation provides a fast, effective
and safe alternative to bipolar resectoscopy in the hysteroscopic
treatment of endometrial polyps, but future trials are required for
other types of intrauterine pathology, as well as comparison of
different hysteroscopic morcellation techniques. Possible benefits about
training, clinical impact and cost-effectiveness need to be further
assessed [3].
To date, there are no guidelines defining the limits
of the size, location and number beyond which small diameter
hysteroscopy should be preferred to the resectoscopy. However, there is
generally agreed that resectoscopic treatment of endometrial polyps
should be reserved to patients who are reluctant to tolerate an
ambulatory operative procedure, or where the size and/or number of
polyps or myomas, and/or type of lesions would require an extensive
exploratory procedure [1].
Therefore, endometrial polyps and submucosal myomas less than 2cm in
diameter are treated with small-diameter hysteroscopes, while larger or
multiple endometrial pathologies require the resectoscope [24,25].
The most of available studies compare small diameter
hysteroscopy and resectoscopy in patients undergoing anaesthesia.
However, the combination of a new generation small diameter hysteroscope
and a new bipolar electrode enables the gynaecologist to treat
intrauterine pathologies in an office setting without anaesthesia [24]. This is an additional benefit in patients who cannot tolerate general or spinal anaesthesia.
Conclusion
According to our opinion the indications for
small-diameter operative hysteroscopy are expanding and not yet
completely defined; in experienced hands a small-diameter hysteroscopy
is a safe and effective approach for benign endometrial disease up to
4cm, especially in patients with unfavourable cervical canal at risk of
cervical injury. Hysteroscopic morcellation is an enhanced alternative
to the small diameter hysteroscopy even if with higher costs.
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