Fritz Nagele

2500 Outpatient diagnostic hysteroscopies

Objective To evaluate the feasibility and acceptability of outpatient diagnostic hysteroscopy. Methods The outcome of 2500 consecutive outpatient hysteroscopies was analyzed. Cervical dilation was performed when necessary and local anesthesia was not administered routinely. Endometrial biopsy and minor hysteroscopic procedures were carried out when indicated. Findings and outcome were compared according to patient characteristics. Results The most common indication for hysteroscopy was abnormal uterine bleeding (87%). Hysteroscopy was performed successfully in 96.4%, and a complete view of the uterine cavity was obtained in 88.9%. Local anesthesia was used in 29.8% and was associated with the need for cervical dilation; both local anesthetic use and cervical dilation were significantly more often required in nulligravid, nulliparous, and postmenopausal women. Intrauterine pathology was diagnosed in 48%, the highest incidence being found in those 50–60 years old (53.7%). The presence of fibroids was the most common abnormality (24.3%) but was seen in only 6.8% of women older than 60 years. Conversely, the incidence of endometrial polyps increased with age, up to 20.5% in women over 60 years. Endometrial biopsy was performed in 68% and produced adequate tissue for histologic examination in 83.7%. Endometrial hyperplasia or carcinoma was detected in 1%. One hundred sixteen women (4.6%) underwent a minor hysteroscopic procedure. Conclusion Outpatient diagnostic hysteroscopy is both feasible and acceptable in the overwhelming majority of cases, with a high detection rate for intrauterine pathology. This procedure may become as routine in the 21st century as D&C has been in the 20th.

Closure or nonclosure of the visceral peritoneum at cesarean delivery

OBJECTIVE Our purpose was to determine whether nonclosure of the visceral peritoneum at low transverse cesarean delivery has advantages over suture peritonization with regard to postoperative morbidity. STUDY DESIGN A prospective randomized trial of 549 women undergoing cesarean section was carried out; 262 were randomized to nonclosure and 287 to closure of the visceral peritoneum. Perioperative, intraoperative, and postoperative management decisions were made without reference to treatment groups. Statistical analysis compared intraoperative and postoperative outcome between the two groups. RESULTS Operating and anesthesia times were significantly shorter in patients receiving nonclosure. The incidence of febrile morbidity and cystitis and the need for antibiotics and narcotics were all significantly greater when the peritoneum was closed. Hospital stay was significantly shorter after nonclosure. CONCLUSION Nonclosure of the visceral peritoneum is associated with lower febrile and infectious morbidity. Routine closure of the visceral peritoneum should be abandoned at cesarean delivery.

Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial

OBJECTIVE To assess the efficacy of lignocaine spray during outpatient hysteroscopy in reducing the need for additional anesthesia and reducing the discomfort of the procedure. DESIGN A randomized double-blind, placebo-controlled trial. SETTING An undergraduate university teaching hospital in London. PATIENT(S) One hundred twenty patients undergoing outpatient hysteroscopy. INTERVENTION(S) Application of lignocaine spray to the cervix, cervical canal, and uterine cavity during outpatient hysteroscopy. MAIN OUTCOME MEASURE(S) The need to use additional anesthesia and the pain experienced at various steps of the procedure. RESULT(S) Women treated with active spray experienced significantly less pain when the cervix was grasped with a tenaculum at the start of hysteroscopy. There were no other significant differences in the outcome of hysteroscopy between the placebo and lignocaine groups, although there was a significant reduction in the use of additional anesthesia in both groups compared with historical controls. CONCLUSION(S) Lignocaine spray has beneficial effects on cervical but not uterine sensation. Pretreatment with either lignocaine or placebo seems to reduce the need for additional intracervical anesthesia during hysteroscopy.

Randomised placebo controlled trial of mefenamic acid for premedication at outpatient hysteroscopy: a pilot study

An increasing number of diagnostic hysteroscopies are being performed in an outpatient setting. Most women tolerate the examination well, but die single commonest reason for failure is pain. We assessed the efficacy of a nonsteroidal, anti‐inflammatory analgesic as premedication before hysteroscopy in a double‐blind, placebo controlled trial. Our results showed that 500 mg mefenamic acid given one hour before hysteroscopy had no significant benefit in the discomfort experienced during the procedure but did signficantly reduce pain after hysteroscopy. A larger dose or a longer interval between premedication and hysteroscopy may possibly be associated with greater benefits.

Comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy

OBJECTIVE To evaluate patient acceptance and the clinical feasibility of carbon dioxide compared with normal saline for uterine distension in outpatient hysteroscopy. DESIGN Prospective, randomized clinical trial. SETTING Outpatient hysteroscopy clinic in a university hospital. PATIENTS One hundred fifty-seven patients undergoing outpatient hysteroscopy. INTERVENTIONS Outpatient hysteroscopy was performed with carbon dioxide or normal saline with endometrial biopsy when indicated. MAIN OUTCOME MEASURES Need for local anesthesia, cervical dilatation, view of uterine cavity, need to change from carbon dioxide to normal saline distension, procedure time, patient discomfort (lower abdominal pain, shoulder tip pain, nausea) and complications. RESULTS Carbon dioxide was used for uterine distension in 79 women and normal saline was used in 78. Cervical dilatation was required more often with carbon dioxide hysteroscopy, although there was no increased requirement for local anesthesia. Hysteroscopic vision was similar between the two media, but eight carbon dioxide cases had to be converted to liquid distension. Procedure times were significantly longer for carbon dioxide hysteroscopy as was the occurrence of bubbles during the procedure. Lower abdominal pain and shoulder tip pain were significantly worse with carbon dioxide distension. Although the incidence of nausea and vomiting was higher with the use of carbon dioxide, the differences did not achieve statistical significance. CONCLUSION The use of normal saline for uterine distension had no adverse affects on the hysteroscopic view. It provided a shorter operating time and was well accepted by patients. Because of its easy availability and low cost, normal saline is an excellent alternative to carbon dioxide in women undergoing outpatient hysteroscopy.

Why Do Women Choose Endometrial Ablation Rather Than Hysterectomy

OBJECTIVE To determine why women choose endometrial ablation rather than hysterectomy for the treatment of menorrhagia. DESIGN Observational study based on postal questionnaires. SETTING A university hospital. PATIENT(S) One hundred eighty randomly selected patients from a cohort of 658 patients who underwent endometrial ablation for the treatment of menorrhagia during the past 7 years. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Patient attitude about endometrial ablation. RESULT(S) One hundred six questionnaires (58.9%) were completed satisfactorily. The average postoperative follow-up period was 45.1 months (range, 3-80 months). Eleven women (10.4%) had undergone repeated endometrial ablation and 8 (7.5%) had undergone hysterectomy. More than half the women indicated that they would find endometrial ablation acceptable even if there was no chance of amenorrhea, if the probability of menstruation becoming lighter was > or = 4:10, if the likelihood of menstrual pain decreasing was > or = 3:10, if the chance of requiring repeated endometrial ablation or hysterectomy was < or = 1:4, and if the risk of uterine cancer after surgery was < or = 1:200. The three most important advantages of endometrial ablation over hysterectomy were perceived to be the avoidance of major surgery, the fast return to normal functioning, and the short hospitalization. CONCLUSION(S) Most women who choose endometrial ablation rather than hysterectomy as therapy for menorrhagia are prepared to undergo hysteroscopic surgery even if the chance of success is relatively poor.

Hysteroscopy in women with abnormal uterine bleeding on hormone replacement therapy: a comparison with postmenopausal bleeding

OBJECTIVE To determine the role of outpatient diagnostic hysteroscopy in patients with abnormal uterine bleeding (AUB) on hormone replacement therapy (HRT) and to contrast this with a control group of women presenting with postmenopausal bleeding. DESIGN Comparative observational study. SETTING Outpatient hysteroscopy clinic in a university hospital. PATIENTS Three hundred ten patients undergoing outpatient hysteroscopy. INTERVENTIONS Outpatient diagnostic hysteroscopy with endometrial biopsy when indicated. MAIN OUTCOME MEASURES Hysteroscopic findings, need for cervical dilatation and local anaesthesia, correlation between hysteroscopy and histologic diagnosis. RESULTS There were 157 (7.1%) patients with AUB on HRT and another 153 (6.9%) with postmenopausal bleeding out of 2,203 outpatient hysteroscopies. Hysteroscopy was successful in 97% and 92% of patients, respectively, and intrauterine pathology was diagnosed in 46.7% and 39.7% of these cases. Functional endometrium was noted significantly more often with HRT and endometrial atrophy with postmenopausal bleeding. Overall, local anesthesia was used in 126 (40.6%) and shown to be associated significantly with the need for cervical dilatation. Endometrial biopsy was attempted in 125 (80%) and 119 (78%) patients in the study and control groups, but was unsuccessful significantly more often with postmenopausal bleeding (38.7%) versus 16%). There were six cases of endometrial carcinoma, all in the control group. CONCLUSION There is a high incidence of intrauterine abnormalities in women with menstrual symptoms while taking HRT, but the pathology differed from those with postmenopausal bleeding. As focal lesions are found commonly in such patients, their detection by diagnostic hysteroscopy should improve compliance with HRT as it would allow individualization of treatment.

Combined ultrasonographically guided drainage and laparoscopic excision of a large ovarian cyst

Large ovarian cysts are conventionally treated by laparotomy. We describe a technique of transabdominal drainage under ultrasonographic control followed by laparoscopic excision of an ovarian cyst that was 24 x 10 x 20 cm. This approach has the benefits of minimal-access surgery and is suitable for unilocular benign cysts of any size.

Laparoscopic excision of a noncommunicating rudimentary uterine horn

Case report A 34 year old PO+1 had an uncomplicated termination of pregnancy at 8 to 10 weeks of gestation in 1980 in Yugoslavia and she was then advised by her gynaecologist that she had a bicornuate uterus. After that, she started to have right sided abdominal and pelvic pains. The pain was colicky in nature and intermittent, occurring every three to four months and lasting from several hours to two to three days. She was referred to our unit because of increasing severity and frequency of her pelvic pain and severe dysmenorrhoea. Transvaginal ultrasound demonstrated a bicornuate uterus with a single cervix. A hysterosalpingogram showed a single uterine cavity with free flow of contrast through the left fallopian tube, and spill was seen into the peritoneal cavity on the left side. An intravenous urogram showed a single left kidney and ureter. A diagnostic hysteroscopy and laparoscopy were done. Laparoscopic evaluation revealed a bicornuate uterus, the right horn looking bigger than the left. Both uterine tubes and ovaries looked normal in appearance, but methylene blue filled and spilled from only the left side with no communication to the right. There was a 4 x 5 cm left para-ovarian cyst and evidence of mild endometriosis in both ovarian fossae and uterosacral ligaments. Hysteroscopic evaluation confirmed a single cervix and a left tuba1 ostium, but no communication to the right horn. In view of her progressive pelvic pain and severe dysmenorrhoea which failed to respond to nonsteroidal anti-inflammatory analgesics, laparoscopic excision of the right uterine horn under