Luigi Nappi

What does 'diagnostic hysteroscopy' mean today? The role of the new techniques.

Purpose of review Visual examination of the uterine cavity and contextual operative facilities have provided the gynecologist with the perfect ‘diagnostic’ tool, making it possible to examine the cavity and biopsy suspected areas under direct visualization. Recent findings The approach used to insert the scope, together with the diameter of the hysteroscope and the distention of the uterine cavity, are of extreme importance in reducing patient discomfort to a minimum during an outpatient examination. The vaginoscopic approach (without speculum or tenaculum) has definitively eliminated patient discomfort related to the traditional approach to the uterus. One of the major problems for endoscopists is passing through the internal cervical os; the new generation of hysteroscopes, with an oval profile and a total diameter between 4 and 5 mm, are strictly correlated to the anatomy of the cervical canal. Miniaturized instruments have enabled the physician not only to perform targeted hysteroscopic biopsies, but also to treat benign intrauterine pathologies, such as polyps and sinechiae, without any premedication or anesthesia. This has been defined as a ‘see & treat’ procedure: there is no longer a distinction between the diagnostic and operative procedures, but a single procedure in which the operative part is perfectly integrated in the diagnostic work‐up. Summary Diagnostic hysteroscopy has long paid the price of being a purely visual method of investigation. Today, thanks to recent advances in instrumentation and to modified techniques related to the simultaneous use of the scope and of instruments, hysteroscopy is finally achieving the full accuracy that has been awaited for the last 20 years.

Review of New Office-Based Hysteroscopic Procedures 2003–2009

Office operative hysteroscopy is a recent technique that enables treatment of uterine pathologic disorders in the ambulatory setting using miniaturized hysteroscopes with mechanical or electric instruments. The available international literature from 1990 to 2002 has clearly demonstrated that such technique enables performance of hysteroscopically directed endometrial biopsy and treatment of uterine adhesions, anatomic disorders, polyps, and small myomas safely and successfully without cervical dilation and the need for anesthesia. This review provides a comprehensive survey of further advancements of office operative hysteroscopy in the treatment of other gynecologic pathologic conditions that have not been included in the schema of treatment indications for office procedures proposed in 2002. A search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified articles published from 2003 to 2009. Eighteen articles were identified: 9 on hysteroscopic sterilization; 1 on office-based metroplasty, 8 on office-based treatment of some uncommon gynecologic pathologic conditions (e.g., hematometra, diagnosis and treatment of vaginal lesions, treatment of uterine cystic neoformations, bleeding from the cervical stump, diagnosis and treatment of endocervical ossification, and removal of uterovaginal packing). All performed procedures were carried out safely and successfully in the office setting, with high patient tolerance and minimal discomfort. The success of the procedures has been confirmed by resolution of symptoms and at follow-up ultrasonographic and hysteroscopic examinations. Currently, as a result of technologic advancements and increased operator experience, an increasing number of gynecologic pathologic conditions traditionally treated in the operating room may be treated safely and effectively using office operative hysteroscopy.

Natural pregnancy in hypothyroid woman complicated by spontaneous ovarian hyperstimulation syndrome

A unique case of life-threatening spontaneous ovarian hyperstimulation syndrome, resulting from severe untreated hypothyroidism, was observed in a woman who conceived spontaneously and gave birth to a normal viable infant.

Four chamber view plus three-vessel and trachea view for a complete evaluation of the fetal heart during the second trimester.

Abstract Objective: To test the efficacy of a recently introduced ultrasonic scanning plane (three vessel and trachea view -3VTV- plus color flow mapping -3VTVC) on a low-risk population for detection of congenital heart disease (CHD). Patients and setting: Antenatal clinic dealing with local low-risk population. All antenatal patients having a second trimester scan in a 1 year period. All patients had a 3VT plus 3VTC views added to routine four chamber view. Postnatal examinations were performed according to standard hospital protocol. Results: 2847 patients were examined. The plane was achievable in all 23 fetuses with CHD detected, three false negative (aortic coarctation) and two false positive. Sensitivity of the examination was 88.5%, as high as more sophisticated and difficult targeted cardiac scanning. The extra time necessary to perform the test was minimal. Conclusion: 3VTV and 3VTCV were satisfactory used as imaging planes in a busy antenatal clinic in a low-risk population. They could be easily added to the four chamber view as routine screening for CHD and increase the detection rate to 90%.

Evaluation of functional ovarian reserve in 60 patients

Diminished ovarian reserve is a condition occurring in women at any adult age, although it is more frequent in women in their 30s and in couples with unexplained subfertility. Different tests are employed to diagnose the problem. The most common are basal tests for FSH, LH, oestradiol and inhibin B, or dynamic endocrine tests such as the clomiphene citrate challenge test and gonadotrophin analogue stimulating test. In recent years, great attention has been devoted to direct tests such as the antral follicle count and ovarian biopsy results. The basal FSH concentration is the most common test utilized for ovarian screening. An abnormal value is correlated with a decrease in pregnancy rate and an increase in cycle cancellation rate. Among other basal endocrine tests, inhibin concentrations appear promising, although more data are necessary before this can be included in clinical practice. The clomiphene citrate challenge test can unmask patients who might have not been detected by basal FSH screening alone, and appears to be more sensitive than day 3 FSH alone. A prospective study was performed on the simultaneous application of various markers of ovarian reserve (FSH, LH, oestradiol, inhibin B, antral follicle count) in the natural cycle preceding assisted reproductive therapy, in 60 women. The present study suggests that counting ovarian follicles by ultrasound appears, at the moment, the most reliable test of ovarian reserve, although it is influenced by subjective factors and more studies are needed in order to confirm its predictive value.

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

Background:The authors tested the hypothesis that during laparoscopic surgery, Trendelenburg position and pneumoperitoneum may worsen chest wall elastance, concomitantly decreasing transpulmonary pressure, and that a protective ventilator strategy applied after pneumoperitoneum induction, by increasing transpulmonary pressure, would result in alveolar recruitment and improvement in respiratory mechanics and gas exchange. Methods:In 29 consecutive patients, a recruiting maneuver followed by positive end-expiratory pressure 5 cm H2O maintained until the end of surgery was applied after pneumoperitoneum induction. Respiratory mechanics, gas exchange, blood pressure, and cardiac index were measured before (TBSL) and after pneumoperitoneum with zero positive end-expiratory pressure (TpreOLS), after recruitment with positive end-expiratory pressure (TpostOLS), and after peritoneum desufflation with positive end-expiratory pressure (Tend). Results:Esophageal pressure was used for partitioning respiratory mechanics between lung and chest wall (data are mean ± SD): on TpreOLS, chest wall elastance (Ecw) and elastance of the lung (EL) increased (8.2 ± 0.9 vs. 6.2 ± 1.2 cm H2O/L, respectively, on TBSL; P = 0.00016; and 11.69 ± 1.68 vs. 9.61 ± 1.52 cm H2O/L on TBSL; P = 0.0007). On TpostOLS, both chest wall elastance and EL decreased (5.2 ± 1.2 and 8.62 ± 1.03 cm H2O/L, respectively; P = 0.00015 vs. TpreOLS), and PaO2/inspiratory oxygen fraction improved (491 ± 107 vs. 425 ± 97 on TpreOLS; P = 0.008) remaining stable thereafter. Recruited volume (the difference in lung volume for the same static airway pressure) was 194 ± 80 ml. PplatRS remained stable while inspiratory transpulmonary pressure increased (11.65 + 1.37 cm H2O vs. 9.21 + 2.03 on TpreOLS; P = 0.007). All respiratory mechanics parameters remained stable after abdominal desufflation. Hemodynamic parameters remained stable throughout the study. Conclusions:In patients submitted to laparoscopic surgery in Trendelenburg position, an open lung strategy applied after pneumoperitoneum induction increased transpulmonary pressure and led to alveolar recruitment and improvement of Ecw and gas exchange.

Are Diabetes, Hypertension, and Obesity Independent Risk Factors for Endometrial Polyps?

STUDY OBJECTIVE To investigate whether diabetes, hypertension (HTN), and obesity can be considered risk factors for endometrial polyps (EPs) independently of age and menopausal status. DESIGN Retrospective analysis (Canadian Task Force classification III). SETTING Department of Obstetrics and Gynecology of the University of Foggia, Italy. PATIENTS A total of 353 Caucasian women undergoing office hysteroscopy to assess abnormal uterine bleeding, infertility, cervical polyps, and abnormal sonographic patterns. INTERVENTIONS Demographic characteristics and data on diabetes, HTN, and menopausal status were collected and anthropometric parameters were analyzed. Vaginoscopic hysteroscopy was performed with a 5-mm continuous-flow operative office hysteroscope. When present, EPs were treated during the same procedure by means of 5-Fr scissors or electrode. MEASUREMENTS AND MAIN RESULTS In 134 (38%) of 353 cases, EPs were found. Univariable and multivariable analysis were performed to verify the presence of a statistically significant association among age, menopause, HTN, obesity, diabetes (independent variables), and the presence of EPs. Univariable logistic analysis showed a statistically significant association among age, menopause, HTN, obesity, and the presence of EPs. However, when multivariable logistic regression was performed, all the independent variables, except age, lost statistical significance (OR 1.05, 95% CI 1.02-1.07, p <.001). CONCLUSION Although it appears that EP is a disorder of aging, the significance of diabetes, HTN, and obesity, as well as menopause, on the development of EPs should be reconsidered.

Uterine cavity assessment in infertile women: comparison of transvaginal sonography and hysteroscopy

OBJECTIVES To evaluate the diagnostic accuracy of transvaginal sonography (TVS) in detecting uterine cavity abnormalities in infertile patients, with reference to hysteroscopy as the gold standard method. STUDY DESIGN At the Institute of Obstetrics and Gynaecology, University of Bari, 134 infertile women were investigated with both TVS and hysteroscopy. In all cases endometrial biopsy was performed. Sensitivity, specificity, and positive and negative predictive values were calculated for TVS, considering hysteroscopic diagnosis as the gold standard. Statistical analysis was performed by using McNemar test. RESULTS There was one failed insertion of hysteroscope. Hysteroscopy diagnosed pathological findings in 58 out of 133 cases (44%). TVS was in agreement with 50 of the 58 (86%) of the pathological findings diagnosed at hysteroscopy. As a test for the detection of uterine cavity abnormalities, TVS in comparison with hysteroscopy had 84.5% sensitivity and 98.7% specificity, 98.0% positive predictive value and 89.2% negative predictive value. CONCLUSIONS TVS is able to diagnose polyps, septum and submucous fibroids with quite significant accuracy, while hysteroscopy is indicated for their confirmation and removal. Thus, hysteroscopy provides both diagnostic and therapeutic capabilities, but TVS permits to proceed directly to operative hysteroscopy avoiding the need for a separate diagnostic procedure.

Dienogest. A possible conservative approach in bladder endometriosis. Results of a pilot study

Abstract Deep endometriosis involvement of the bladder is uncommon but it is symptomatic in most of the cases. Although laparoscopic excision is very effective, some patients with no pregnancy desire require a medical approach. We performed a pilot study on the effect of a new progestin dienogest on bladder endometriosis. Six patients were treated for 12 months with dienogest 2 mg/daily. Pain, urinary symptoms, quality of life, nodule volume and side effects were recorded. During treatment, symptoms improved very quickly and the nodules exhibit a remarkable reduction in size. Dienogest may be an alternative approach to bladder endometriosis.

A Multicenter, Double-Blind, Randomized, Placebo-Controlled Study to Assess Whether Antibiotic Administration Should Be Recommended During Office Operative Hysteroscopy

We did a double-blind, randomized, placebo-controlled study to assess the incidence of infectious complications and the protective effect of antibiotic administration during operative hysteroscopic procedures in an office setting. A total of 1046 consecutively enrolled women with intrauterine lesions were randomly allocated to the reference group (523 patients administered with 1 g of cefazolin intramuscularly) and the study group (523 patients administered with 10 mL of isotonic sodium chloride solution), and treated in office setting by operative hysteroscopy for endometrial polypectomy, uterine septa, submucosal myomas, and intrauterine adhesions. The primary outcome measure was the computation of difference between groups in postsurgical infectious complications occurring in the 5 days after the procedures. The time spent in performing the various procedures did not differ significantly (P > .05) between the groups. With respect to the overall rate of postsurgical infection, we found that 12 (1.15%) of 1046 patients referred with symptoms related to infective complications, 7 (1.3% of 523 women) in the study—untreated—group and 5 (1.0% of 523 women) in the reference group. Such incidences did not differ significantly between the groups (P > .05). Antibiotics were prescribed in all cases of postsurgical infection and the infective process resolved in few days. None of these patients developed serious infections with adnexal involvement, as confirmed by clinical and ultrasounds evaluation. The results of the current study would support the American College of Obstetricians and Gynecologists recommendation not to prescribe routine antibiotic administration in the case of hysteroscopic surgery.