Hugh O'Connor

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.

Vaginal hysterectomy for the large uterus

Objective To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size.

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.

A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy

Objective To assess the feasibility and safety of vaginal removal of ovaries at the time of vaginal hysterectomy.

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

Subtotal vaginal hysterectomy

SummaryFive women requiring hysterectomy for benign indications and with normal cervical cytology, underwent the new procedure of subtotal (supracervical) vaginal hysterectomy combined with salpingo-oophorectomy in two cases. Using the Doderlein-Kronig approach, an anterior colpotomy was made and the uterine fundus delivered into the vagina. The ovarian and uterine pedicles were ligated in turn before amputating the uterine body from the cervix. The cervical incision was then repaired and the vaginal incision closed. Operative times ranged from 35 to 150 min, one procedure being prolonged by difficulty with bladder dissection following two previous Caesarean sections. Subtotal vaginal hysterectomy is an alternative to abdominal and laparoscopic subtotal hysterectomy, which avoids two of the disadvantages of these techniques, the need for abdominal incisions and the need for laparoscopic expertise.

Treatment of dysfunctional uterine bleeding. Appropriate comparison would be to compare the best of the old treatments with the best of the new.

EDITOR,—S B Pinion and colleagues compared hysterectomy with endometrial ablation in the management of menorrhagia and not just dysfunctional uterine bleeding as suggested in the title of their paper.1 Of the group treated conservatively, 29% had positive findings, mainly fibroids; the percentage with positive findings rose to 34% in those treated by hysterectomy. While there is no evidence that endometrial ablation is appreciably less effective in women with small submucous fibroids,2 the title is nevertheless misleading. We have two, …

Ovarian cancers related to minimal access surgery

Objective To review the clinical features of women with ovarian cancer on whom minimal access surgery has been performed and to determine guidelines for the safe use of minimal access surgery for adnexal masses. Design Postal survey of members of the British Gynaecological Cancer Society (BGCS) and retrospective case review. Results BGCS consultants used ultrasound scanning (70%) and serum CA-125 estimations (53%) prior to adnexal mass surgery. The membership felt that adnexal masses with solid elements, diameter greater than 8 cm, multi-ocular or bilateral cysts or increased blood flow on Doppler scanning should not be operated on by minimal access surgery. A positive family history was also considered to be a contraindication. A total of 29 cases of ovarian cancer were identified on whom MAS had been performed. The incidence of cases was 4.1% of referrals to a tertiary referral centre (the Royal Marsden Hospital). The median age of patients was 37 years (range 20 to 68 years) and 13 had Stage I cancers. The mean delay between diagnosis and staging was 6.5 weeks. Conclusion Guidelines on the use of minimal access surgery in the management of adnexal masses need to be agreed. Women who have an ovarian cancer diagnosed whilst having minimal access surgery should have an accepted staging procedure. We do not recommend the routine use of minimal access surgery for the treatment of ovarian cancer outside a trial.