D Marconi

Hysterosalpingo-contrast sonography compared with hysterosalpingography and laparoscopic dye pertubation to evaluate tubal patency.

STUDY OBJECTIVE To evaluate the advantages and accuracy of hysterosalpingo-contrast sonography (HyCoSy) in assessing tubal patency compared with hysterosalpingogram (HSG) and laparoscopic dye pertubation. DESIGN Prospective study (Canadian Task Force classification II-2). SETTING Obstetrics and Gynecology Department, University of Rome Tor Vergata. PATIENTS Twenty-three women with at least 1 year of infertility, and 15 women with a history of chronic pelvic pain, suspected endometriosis, or pelvic inflammatory disease (PID), or with sonographic markers of adhesions. INTERVENTIONS HyCoSy, HSG, and laparoscopic dye pertubation. MEASUREMENTS AND MAIN RESULTS All patients underwent HyCoSy during the proliferative phase using air with saline as contrast medium, and HSG within 1 month of HyCoSy. Laparoscopy and dye pertubation were performed only in women with chronic pelvic pain, suspected endometriosis, PID, and sonographic markers of adhesions. In women undergoing all three procedures, HSG and HyCoSy had the same high concordance as laparoscopy, 86.7% and 86.7%, respectively. Three women in the infertility group became pregnant immediately after HyCoSy and dropped out of the study. In one woman, HyCoSy could not be performed because of cervical stenosis. Considering the total number of tubes (67), concordance between HyCoSy and HSG was 89.6%. CONCLUSION Transvaginal HyCoSy using a combination of air and saline appears to be an inexpensive, fast, and well-tolerated method of determining tubal patency. One of the most important advantages of this technique is, in our opinion, the possibility of obtaining information on tubal status and the uterine cavity at the same time as conventional ultrasound scan is performed.

Staging of Pelvic Endometriosis: Role of Sonographic Appearance in Determining Extension of Disease and Modulating Surgical Approach

Abstract Study Objective To estimate whether laparoscopic staging of endometriosis can be predicted by ultrasound findings. Design Prospective study (Canadian Task Force classification II-2). Setting Obstetrics and Gynecology Department, University of Rome Tor Vergata. Patients One hundred twenty-one women with histologically confirmed sonographic diagnosis of endometriomas. Intervention Ultrasonographic staging and laparoscopic assessment. Measurements and Main Results All patients underwent transvaginal and/or transrectal sonographic evaluation of ovarian endometriomas and other sonographic markers (anatomic sites and their relation to abdominovaginal palpation, adhesions, deep or infiltrating nodules) to stage the disease before surgery. These results were compared with laparoscopic staging. Concordance between methods was 83.5%. Specificity and sensitivity of ultrasonographic staging of stages 3 and 4 disease were 86% and 82% and 76% and 91%, respectively. Conclusion Ultrasonographic findings can predict pelvic extension and stage of endometriosis.

Outpatient diagnostic hysteroscopy.

STUDY OBJECTIVE To evaluate the feasibility, validity, indications, and results of a large series of diagnostic hysteroscopies performed without anesthesia. DESIGN Retrospective analysis of hysteroscopy charts performed between 1989 and 1996 (Canadian Task Force classification II-2). SETTING University-affiliated endoscopy unit. PATIENTS Four thousand consecutive women referred for different indications. INTERVENTIONS Diagnostic hysteroscopy was performed in 91% of patients without premedication or anesthetics. In some women premedication or general or local anesthesia was required to access the uterine cavity. MEASUREMENTS AND MAIN RESULTS The success rate, validity indication, complication rate, and number of biopsies were critically evaluated and assessed in relation to increased experience of operators. In 91% of women we accessed the uterine cavity at the first attempt without premedication, whereas 207 (5. 1%) patients required local anesthesia and 99 (2.4%) premedication. Only 1.6% required general anesthesia. In 52% intrauterine pathology was diagnosed and in 21% further surgical treatment was suggested. CONCLUSION Hysteroscopy was feasible when performed in an outpatient setting without general or local anesthesia in more than 90% of women. The operators experience seems a key factor both for accurate endometrial evaluation and to reduce failure and endometrial biopsy rates. The low frequency of further surgical treatment justifies performing the procedure in the office.

Laparoscopic approach to dermoid cysts: Combined surgical technique and ultrasonographic evaluation of residual functioning ovarian tissue

STUDY OBJECTIVE To estimate how and if laparoscopic removal of ovarian dermoid cysts is a tissue-sparing procedure. DESIGN Prospective study (Canadian Task Force classification II-2). SETTING University-associated hospital. PATIENTS Fifty-five women. INTERVENTION Laparoscopic removal of ovarian dermoid cysts by a combination of hydrodissection and blunt dissection, and transvaginal sonographic (TVS) evaluation of residual ovarian tissue. MEASUREMENTS AND MAIN RESULTS Within 1 week before surgery all recruited patients underwent TVS evaluation of ovarian volume, size, and morphology of dermoid cysts and measurement of surrounding ovarian cortex. Mean cyst diameter was 5.5 +/- 2.2 cm (range 2.1-15.0 cm). Within 6 to 12 months after laparoscopic excision, TVS measurements of residual ovarian tissues were obtained. Ovarian residual cortex surrounding the cyst was not visible at TVS in 24 ovaries, whereas in 56 ovaries residual tissue volume was greater than 3 cm3 after laparoscopic excision. CONCLUSION We propose laparoscopic removal of dermoid cysts by combining hydrodissection and blunt dissection with maximum tissue sparing, even when the cyst seems to fill the ovary and no surrounding ovarian cortex can be seen on ultrasound.

A New Hysteroscopic Classification of and Nomenclature for Endometrial Lesions

STUDY OBJECTIVE To establish a hysteroscopic classification of endometrial lesions based on a combined score: DESIGN A prospective study to grade four features of endometrial lesions (thickness, surface, color, vascularization) and subdivide them as mild (low risk) and severe (high risk). SETTING Gynecologic endoscopy unit of an obstetric and gynecology clinic. PATIENTS Two hundred twenty-nine women with hysteroscopically diagnosed endometrial lesions. INTERVENTIONS Hysteroscopic inspection of endometriotic lesions, with grading performed on the four features. MEASUREMENTS AND MAIN RESULTS The sensitivity and specificity of our system were 86.9% and 87.4% for mild pathology, and 96% and 92.9% for severe pathology. CONCLUSIONS This hysteroscopic classification of endometrial pathology can be useful for a better definition of endometrial lesions. The method has good sensitivity and specificity.

Pain Mapping During Minilaparoscopy in Infertile Patients without Pathology

STUDY OBJECTIVE To draw a map of pelvic pain and quantify the level of provoked pain during minilaparoscopy under local anesthesia and conscious sedation. DESIGN Observational study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS Twenty infertile women. INTERVENTIONS Minilaparoscopy was performed under local anesthesia and conscious sedation, and cognitive performance was evaluated with the Rey auditory verbal learning task. MEASUREMENTS AND MAIN RESULTS The diagnostic procedure was performed with one 2-mm micrograsper and one 2-mm microprobe to evaluate the pelvis. In particular we grasped utero-ovarian ligaments; we touched, grasped, and distended fallopian tubes with blue dye; we moved the uterus with a manipulator inserted at the cervix; and we touched and grasped bowel and omentum. Level of pain was recorded on a visual analog scale. Patients had no pathologic findings, including minimal endometriosis and pelvic adhesions. The highest level of pain was recorded when we distended the tubes. No pain was elicited when we touched and grasped ovary, omentum, and bowel. In 10% of women when we stretched the tubo-ovarian ligament we provoked a minimal vagal reaction. CONCLUSION Minilaparoscopy under conscious sedation for pelvic pain mapping in women without pain or pathology revealed consistently negative findings, validating the value of this measurement. (J Am Assoc Gynecol Laparosc 6(1):51-54, 1999)

Is local anesthesia an affordable alternative to general anesthesia for minilaparoscopy

STUDY OBJECTIVE To determine if minilaparoscopy under local anesthesia is at least as reliable and affordable as that performed under general anesthesia. DESIGN Prospective, randomized study (Canadian Task Force classification I). SETTING University-affiliated hospital. PATIENTS One hundred sixty-four consecutive women evaluated for infertility. INTERVENTION Diagnostic minilaparoscopy performed after women were randomized to receive general or local anesthesia with conscious sedation. MEASUREMENTS AND MAIN RESULTS Levels of postoperative pain measured by visual analog scale; volume of CO(2) used; length of procedure, complete pelvic evaluation, and hospitalization; complications; and pathologic diagnosis were evaluated. The groups were comparable in age, years of infertility, and symptoms. For women receiving local anesthesia, 5.5% required general anesthesia to complete the procedure. Women in both groups required postoperative analgesics. The groups had no statistically significant differences in pain level 1 hour after the procedure, number of complications, and pelvic pathology. Patients who had local anesthesia required a smaller volume of CO(2) (p <0.01) and their hospitalization was significantly shorter (p <0.01). However, in 15% of these women pelvic visualization was incomplete, compared with 7.2% in the general anesthesia group. CONCLUSION Minilaparoscopy performed under local anesthesia was as reliable and affordable as when performed under general anesthesia.

Costs and benefits of office diagnostic hysteroscopy

In Italy, the main location for performing diagnostic hysteroscopy is the office. The success of office hysteroscopy is related to savings of time and money and the convenience for the physician and patient. We evaluated 4000 diagnostic hysteroscopies performed between January 2, 1989, and March 1, 1996. In 17.8% of these patients we subsequently performed operative hysteroscopies (metroplasty, synechiolysis, myomectomy, polypectomy for polyps >2 cm), and in 5.2% a total abdominal hysterectomy for abnormal uterine bleeding or endometrial cancer. The low percentage of operations underlines the efficacy of office diagnostic hysteroscopy, especially if we evaluate costs and accuracy of this procedure in detecting uterine pathologies.

Vaginal Ultrasonography and Diagnostic Hysteroscopy for Women with Abnormal Uterine Bleeding after Menopause

Three hundred twenty-five postmenopausal women with abnormal uterine bleeding had transvaginal ultrasound examinations. In 158 the endometrial thickness was greater than 5 mm, in 20 less than 5 mm but irregular, and in 147 less than 5 mm and regular. Diagnostic hysteroscopy was performed in the first two groups and showed mild endometrial abnormalities in 23 women, severe in 23, endometrial polyps in 55, myoma in 10, and normal endometrium (atrophic or proliferative) in 22, with synechiae in 5. Forty-six (32%) endometrial biopsies were performed and showed 20 adenocarcinomas, 3 atypical hyperplasias, 10 simple hyperplasias, 5 atrophies, and 8 proliferative. In 18 patients the examination was not possible because of cervical stenosis and was performed under general anesthesia; polyps were removed by operative hysteroscopy. In patients with endometrial thickness greater than 5 mm, hysteroscopy revealed only two cases of mild endometrial abnormalities (cystic atrophy), two polyps, and two myomas. The frequency of endometrial cancer was 7%, similar to that reported by others. Ultrasonography is sensitive in evaluating abnormal uterine bleeding with or without endometrial pathology. Hysteroscopy must be the second procedure because it can exclude pathology and allow a targeted biopsy to confirm the diagnosis.

Hysteroscopic evaluation in patients with thick enedendometrium at vaginal ultrasound examination

The purpose of this study was to evaluate the hysteroscopic appearance of the endometrium in cases with abnormal thickening (>8mm) evaluated by vaginal ultrasound. We considered postmenopausal patients who were asymptomatic and those with abnormal uterine bleeding (AUB). Hysteroscopy with endometrial biopsy revealed cancer, hyperplasia, polyps, and myoma in patients with AUB. In the asymptomatic group with increased endometrial thickening, hysteroscopy revealed hyperplasia, polyps and myoma. Our results show that vaginal ultrasound is a reliable method for evaluation of the endometrium in postmenopausal women. Hysteroscopic examination is required to assess the endometrial pathology, and to determine which patients will require biopsy or surgical intervention.