Aubert Agostini

Postoperative infection and surgical hysteroscopy

OBJECTIVE To evaluate the risk of infection after surgical hysteroscopy. DESIGN Prospective observational study. SETTING University hospital. PATIENT(S) One thousand nine hundred fifty-two patients requiring operative hysteroscopy during a 10-year period from January 1990 to January 2000. INTERVENTION(S) Two thousand one hundred sixteen operative hysteroscopies were performed: 782 fibroma resections, 422 polyp resections, 623 endometrectomies, 90 uterine septa sections, and 199 lyses of synechiae. MAIN OUTCOME MEASURE(S) Postoperative infectious complications. RESULT(S) Thirty (1.42%) infections occurred. There were 18 (0.85%) cases of endometritis and 12 urinary tract infections. No other severe infectious complications were reported. The risk for early-onset endometritis was higher after lysis of synechiae compared with endometrectomy, fibroma, or polyp resections. However, the risk for early-onset endometritis was similar for endometrectomy, septa, fibroma, or polyp resections. CONCLUSION(S) Infectious risk following surgical hysteroscopy is low. No major infectious complications occurred. Risk for early-onset endometritis was higher after lysis of synechiae compared with other procedures.

Risk of Uterine Perforation during Hysteroscopic Surgery

STUDY OBJECTIVE To evaluate the rate of uterine perforation during different operative hysteroscopy procedures. DESIGN Observational study (Canadian Task Force classification II-2). SETTING Department of Obstetrics and Gynecology, La Conception Hospital, Marseille, France. PATIENTS One thousand nine hundred fifty-two women. INTERVENTION Of 2116 operative hysteroscopies performed, there were 623 endometrectomies, 782 myoma resections, 422 polyp resections, 199 adhesiolyses, and 90 uterine septa sections. MEASUREMENTS AND MAIN RESULTS Risk of perforation was evaluated according to hysteroscopic procedure. Severity of complications were also noted. In case of perforation, a management protocol was applied to prevent metabolic disorders and pelvic infections. Thirty-four perforations (1.61%) were reported. In 33 cases (97%) it was realized during the procedure and no complications occurred during follow-up. One perforation with hemorrhage was misdiagnosed during the intervention and required laparotomy. Perforation risk was higher during hysteroscopic adhesiolysis than during other procedures [endometrial ablation RR 9.39 (3.46-25.52), p <0.0001; uterine septa section RR 6.78 (0.91-50.6), p = 0.026; polyp RR 8.52 (2.60-30.80), p <0.0001 or myoma resection RR 7 (2.83-17.62), p <0.0001]. Perforation risk was comparable during endometrial ablation, uterine septa section, and polyp or myoma resection (p = 0.93). CONCLUSION Perforation risk is higher during synechiolysis than in other indications for hysteroscopy. Severe complications are rare but may be avoided if precautions are taken.

Vaginal hysterectomy in nulliparous women without prolapse: a prospective comparative study

Objective To compare vaginal hysterectomy success and complication rates in nulliparous and primiparous or multiparous women.

Risk of vasovagal syndrome during outpatient hysteroscopy

STUDY OBJECTIVE To evaluate influence of hysteroscope type and media used during outpatient hysteroscopy on vasovagal syndrome risk. STUDY DESIGN Prospective observational study (Canadian Task Force classification II-1). SETTING University hospital. PATIENTS Two thousand seventy-nine women undergoing outpatient hysteroscopy without analgesia. INTERVENTION Office hysteroscopy with a flexible or rigid hysteroscope and normal saline or CO(2). MEASUREMENTS AND MAIN RESULTS Fifteen cases of vasovagal syndrome were reported. The rate of vasovagal syndrome was higher with use of a rigid hysteroscope (12/647 [1.85%]) vs. a flexible hysteroscope (3/1432 [0.21%]), p =.00013; p =.009 after adjustment for medium used; and with the use of CO2 (10/426 [2.34%]) vs. saline solution (5/1653 [0.30%]), p <.0001; p =.014 after adjustment for hysteroscope type. CONCLUSION Risk of vasovagal syndrome is higher with the use of a rigid hysteroscope and CO2, regardless of the indication for hysteroscopy or the parity and menopausal status of the patient.

Hemorrhage risk during operative hysteroscopy

Background.  To evaluate the risk of hemorrhage during hysteroscopic surgery.

Endometrial biopsy during outpatient hysteroscopy: evaluation and comparison of two devices

OBJECTIVE Association of office hysteroscopy with outpatient endometrial biopsy is interesting to evaluate correctly endometrium. Purpose of this study was to evaluate and compare two endometrial biopsy devices during outpatient hysteroscopy, based on effectiveness and tolerance of the procedure. STUDY DESIGN A single blind, randomised prospective study. RESULTS 200 patients were randomised into two groups following outpatient hysteroscopy: 100 were biopsied with Vacurette and 100 biopsed with Pipelle. Pipelle was less painful compared to Vacurette (1.1+0.2 versus 1.6+0.3; P<0.001), no matter hormonal status (1+0.3 versus 2+0.6; P<0.001 in premenopausal subgroup and 1+0.3 versus 1.4+0.3; P<0.001 in postmenopausal subgroup). Vacurette was more effective than Pipelle (64/100 versus 48/100; P=0.02), in case of normal or hypertrophic endometrium (56/72 (77%) versus 40/65 (61%); P=0.04) but not in case of atrophic endometrium (8/28 (29%) versus 8/35 (23%); P=0.6). Among the 112 patients with adequate sample, histologic results were normal, except for three cases of endometrial hyperplasia. Among the 88 patients with inadequate sample, 47 (53%) presented an atrophic endometrial aspect at hysteroscopy, whereas 41 (47%) were considered as normal. CONCLUSIONS Vacurette was more effective though more painful than Pipelle. Both instruments were, however, well tolerated. Both instruments were not very effective in case of atrophic endometrium. Outpatient hysteroscopy combined with endometrial biopsy may help avoid further investigations.

Garnerella vaginalis bacteremia after vaginal myomectomy

A 49-year-old woman was referred for evaluation of chronic pelvic pain and genital bleeding. Past medical history was otherwise unremarkable and she had one previous vaginal delivery. Pelvic examination revealed a posterior fibroma. Pelvic sonography confirmed a single interstitial posterior fibroma (65 mm 56 mm 45 mm) and a left anechogenous collection (91 mm 74 mm). At diagnostic laparoscopy adhesiolysis between left tubal and sigmoid was performed and a liquid collection evacuated. The ovaries were normal, but access to the posterior fibroma was limited by synechia between fibroma and rectum. At the end of laparoscopy, vaginal myomectomy was performed. No complication occurred during intervention. Prophylactic antibiotics were given during intervention (cefoxitrin 1 g IV). On postoperative day 3, patient had hyperthermia with pelvic pain. Two blood cultures were positives with Garnerella sp. and one blood culture was positive with Peptostreptococcus sp. Antibiotics including metronidazole were administered. On postoperative day 6, vaginal examination revealed an abscess of the vaginal cuff confirmed by pelvic sonography. Vaginal surgical evaluation was performed. Postoperative evolution as normal and patient discharged on postoperative day 11. 2. Discussion

Influence of peritoneal factors on port-site metastases in a xenograft ovarian cancer model

Objective We determine the main physical effects of pneumoperitoneum on tumour dissemination and port‐site metastases occurrence.

Risk of finding an endometrial cancer when atypical hyperplasia was incidentally diagnosed on hysteroscopic resection products

OBJECTIVE To evaluate the risk of discovering an endometrial cancer when atypical hyperplasia was diagnosed by histologic examination of hysteroscopic resection products. STUDY DESIGN A retrospective monocentric study from January 1994 to January 2001. Seventeen patients with atypical hyperplasia were included. Initial endometrial status was provided by operative hysteroscopy resection products. For all patients, there was no hysteroscopical aspect evocative of adenocarcinoma. Histopathological analysis of the hysterectomy pieces precised the final diagnosis. RESULTS Among the 17 hysterectomy pieces, one adenocarcinoma was diagnosed. Risk for discovering adenocarcinoma when atypical hyperplasia was diagnosed by operative hysteroscopy resection products was 5.9% (1/17). CONCLUSION Risk of omitting adenocarcinoma when atypical hyperplasia is discovered by hysteroscopy resection pieces is low.

Intrauterine pregnancy after thermal balloon ablation

Mrs. T. C., 36-year-old, gravida one, took medical advice in our department in February 1999 for menorrhagia with hemoglobin level less than 10 g/dl. The patient presented a history of coagulation disorder: thrombopathy (type pool vide disease) with bleeding time exceeding 30 minutes. Postpartum hemorrhage followed her first delivery in 1994. Routine physical examination, pelvic ultrasonography, office hysteroscopy and endometrial biopsy performed preoperatively did not show any evident uterine disease. We arrested the diagnosis of abnormal uterine bleeding due to thrombopathy without uterine disease. The patient was treated in March 1999 with the thermal uterine balloon system (ThermaChoice, Gynecare Inc., Manlo Park, CA, USA). Menstrual blood loss was reduced in the postoperative period. In November 2000, the patient presented an 8 week amenorrhea. Pelvic ultrasonography confirmed intrauterine pregnancy. It was an unplanned pregnancy and the patient wanted legally induced abortion. Termination of pregnancy was obtained using dilatation and uterine aspiration under general anesthesia.