Lucie Buck

Outpatient hysteroscopy: traditional versus the ‘no-touch’ technique

Objective  To assess whether outpatient hysteroscopy using the ‘no‐touch’ technique confers any advantages in terms of patient discomfort over the traditional technique.

Surgical and radiological management of uterine fibroids--a UK survey of current consultant practice.

Background.  The aim of this study was to determine the current surgical and radiological management of uterine fibroids by consultants working in the UK.

Intraperitoneal bupivacaine for the reduction of postoperative pain following operative laparoscopy: a pilot study and review of the literature

This pilot case – control study was carried out to determine the value of intraperitoneal irrigation with a long-acting local anaesthetic agent in reducing postoperative analgesic requirements following gynaecological operative laparoscopy. Twenty women undergoing gynaecological laparoscopic surgery were recruited to receive dilute bupivacaine instilled into the peritoneal cavity at the completion of surgery. Analgesic requirements were assessed during the first 10 hours, and pain scores at 4 and 24 hours. Analgesic requirements were then compared with historical controls. Our results revealed that the total parenteral opioid requirement after bupivacaine was significantly less than in the control group (0.50 mg vs. 7.17 mg, P = 0.006). Oral analgesic requirements were not significantly different between the two groups. Pain scores in the bupivacaine group showed no difference at 4 and 24 hours postoperatively. Intraperitoneal irrigation with dilute bupivacaine at the end of gynaecological laparoscopic surgery appears to reduce early postoperative analgesic requirements in this pilot study.

One stop fertility clinic

The objective of this study was to determine the feasibility and acceptability of out-patient based investigation of infertile couples using a prospective observational study based in a large undergraduate teaching hospital. We studied couples referred to secondary care for investigation of their infertility. Investigations involved pelvic ultrasound, diagnostic hysteroscopy and culdoscopy. The main outcome measures were feasability of investigations, findings, patient views, and a management plan. RESULTS 199 of 347 (57.3%) couples referred met our selection criteria, and 162 of this group have attended. Thirty-one (19.1%) were judged to be unsuitable for culdoscopy, and culdoscopy failed in a further 29 (17.9%). The average time for the three procedures was 41.2 (SD 17.2) minutes, and over 1/3 of patients were found to have pelvic pathology. The investigations were well tolerated and there was only one complication necessitating admission to hospital. Most patients appreciated the need for a single hospital visit and the availability of immediate results. CONCLUSIONS A One Stop approach to the investigation of infertility is attractive but not suitable for or desired by all infertile couples. Organisational issues were also identified.

Myomectomy can be 'life saving'--a case of a 36-week fibroid uterus managed conservatively in a 40-year-old nulliparous woman

Discussion Empty pelvis syndrome can be defined as an empty space or cavity following pelvic exenteration which may result in the formation of an abscess, haematoma or lymphocoele, leading to persistent discharge and sinus formation with or without chronic infection. There may be some similarities between this and chronic osteomyelitis, which predisposes to chronic sinus formation and sarcomatous change in bone either spontaneously or as a result of radioor chemotherapy. Unfavourable consequences as described in the case report can be avoided or minimised by procedures for filling the empty pelvis with omental flaps, pedicle myocutaneous flaps from the rectus abdominis or the gracilis muscle or placement of absorbable mesh. These procedures may be effective in preventing small bowel loops from descending into the lower pelvis (Crowe et al., 1999). The possibility of perineal preservation with colo-anal continuity in selected cases may reduce postoperative morbidity following pelvic exenteration (Brodsky et al., 1993). The psychological consequences are considerable. Krouse et al. (1990) describe four stages in the woman’s experience. The first stage, i.e. recognition or exploration, centres on the recognition of symptoms and diagnosis. The crisis or the climate stage occurs when treatment is initiated. The adaptation or maladaptation stage occurs after treatment. The resolution or disorganisation stage occurs after treatment, which concerns the long-term sequele. Guilt, embarrassment, anxiety, isolation and fear or denial of the disease are the hallmarks of the first stage. Anxiety, depression, altered body image and concern about changing relationships characterise the second. The adaptation or maladaptation stage is centred on the patient’s functional status, self-perception changes, stabilisation of interpersonal relationships and employment. Isolation is a risk during that phase, which encompasses the first postoperative year. Resolution rests on an increased involvement in life. This involves an enhanced self-worth and a successful attempt to integrate the experience spiritually. Continuing follow-up of these patients is of great importance to evaluate results, provide reassurance and to give symptomatic relief to those in whom treatment has failed. Frequency of follow-up may vary slightly between centres. A typical recommendation may be 3-monthly follow-up to 2 years and annual visits thereafter.