Stefano Bettocchi

A vaginoscopic approach to reduce the pain of office hysteroscopy

We developed a new approach to diagnostic hysteroscopy that reduces patient discomfort and increases the possible applications of hysteroscopy. Between February 1992 and March 1996, 1200 hysteroscopies were performed at our institution. Of these, the last 680 were done using the vaginoscopic approach without preselection. Discomfort was reduced in all patients, including those with moderate stenosis of the internal cervical os. Vaginoscopy is easy to perform and incurs no additional cost for the patient. It is ideal for office hysteroscopy and in patients who otherwise might require general anesthesia, such as virgins and older women with somewhat stenotic vaginas.

Diagnostic inadequacy of dilatation and curettage

OBJECTIVE To assess the diagnostic inadequacy of dilatation and curettage (D&C) by comparing histologic findings with this technique with those obtained after hysterectomy. DESIGN Retrospective clinical study. SETTING University-affiliated hospital. PATIENT(S) Three hundred ninety-seven patients with abnormal uterine bleeding who underwent D&C and, within 2 months, hysterectomy because of histologic findings or persistence of symptoms. MAIN OUTCOME MEASURE(S) Comparison of histologic findings on D&C with those obtained after hysterectomy. RESULT(S) In 248 of 397 patients (62.5%), D&C failed to detect intrauterine disorders subsequently found at hysterectomy; the sensitivity was 46%, the specificity was 100.0%, the positive predictive value was 100.0%, and the negative predictive value was 7.1%. CONCLUSION(S) Dilatation and curettage is an inadequate diagnostic and therapeutic tool for all uterine disorders; this technique missed 62.5% of major intrauterine disorders, and all endometrial disorders were still present in the removed uterus.

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.

Accuracy of transvaginal sonography and contrast‐enhanced magnetic resonance‐colonography for the presurgical staging of deep infiltrating endometriosis

To investigate the accuracy of transvaginal sonography (TVS) and contrast‐enhanced magnetic resonance‐colonography (CE‐MR‐C) for the presurgical assessment of deep infiltrating endometriosis (DIE).

Comparison of hysteroscopic and hysterectomy findings for assessing the diagnostic accuracy of office hysteroscopy

OBJECTIVE To assess the diagnostic accuracy of office hysteroscopy by comparing the hysteroscopic findings with the histologic findings on the hysterectomy specimens. DESIGN Retrospective clinical study. SETTING University-affiliated hospital. PATIENT(S) Review of the hospital records of 443 patients who underwent office hysteroscopy and, within 2 months, hysterectomy. INTERVENTION(S) We compared the hysteroscopic findings (including targeted biopsies) with the histologic findings that were obtained after hysterectomy. The results of this study were then compared with those of a previous study in which we examined the diagnostic accuracy of dilatation and curettage (D&C). MAIN OUTCOME MEASURE(S) We evaluated the diagnostic accuracy of office hysteroscopy. RESULT(S) When compared with the histologic diagnosis of the uterus, the hysteroscopic findings showed a diagnostic sensitivity of 98%, a specificity of 95%, a positive predictive value (PPV) of 96%, and a negative predictive value (NPV) of 98%. Hysteroscopy was found to have a greater diagnostic accuracy than D&C: the sensitivity and the NPV of the two diagnostic procedures were statistically different. CONCLUSION(S) Office hysteroscopy is confirmed as a powerful diagnostic tool, but targeted biopsies, performed with a small diameter operative hysteroscope, must be performed in cases of suspect endometrium to confirm the image-based diagnosis.

Diagnostic accuracy of hysteroscopy in endometrial hyperplasia

OBJECTIVES To determine the diagnostic accuracy of hysteroscopy in the diagnosis of endometrial hyperplasia in women with abnormal uterine bleeding. METHODS From 1993 through 1995, 980 women referred to our institution for abnormal uterine bleeding underwent diagnostic hysteroscopy with eye direct biopsy of the endometrium in case of macroscopic abnormalities. Hysteroscopic features were compared with pathologic findings in order to detect the reliability of the endoscopic procedure. Statistical analysis was performed with the McNemar test. RESULTS Positive predictive value of hysteroscopy in the diagnosis of endometrial hyperplasia accounted for 63%. In fact hysteroscopic diagnosis of endometrial hyperplasia was confirmed at pathologic examination in 81 out of 128 patients. Sensitivity and specificity of the endoscopic procedure accounted for 98% and 95%, respectively. Negative predictive value accounted for 99%, as only two cases of atypical hyperplasia were missed at hysteroscopy. Positive predictive value was higher in postmenopausal patients compared to women in the fertile age (72 vs. 58%). CONCLUSIONS Overall, results appear encouraging, since no case of endometrial hyperplasia was missed by hysteroscopy. The high diagnostic accuracy, associated with a minimal trauma, renders hysteroscopy the ideal procedure for both diagnosis and follow-up of conservative management of endometrial hyperplasia.

Surgical treatment of recurrent ovarian cancer: report of 21 cases and a review of the literature

AIM To evaluate the role of secondary cytoreductive surgery in patients with recurrent ovarian cancer. PATIENTS AND METHODS A retrospective chart review was conducted on 21 patients submitted to secondary cytoreductive surgery for apparently isolated and resectable recurrence of ovarian cancer, after a disease-free interval of at least 12 months. RESULTS Fifteen patients (71%) had complete surgical debulking with no macroscopic tumor at the completion of the surgical procedure. Eight patients (38%) required an intestinal resection but no colostomy was performed. Eleven complications were recorded in nine patients, but no operative death occurred. The median survival time for all patients after diagnosis of recurrent disease was 29 months (range 6-96 months). Survival time after diagnosis of recurrence was not significantly related either to known prognostic factors of ovarian cancer or to the length of the clinical remission time. The absence of residual disease after salvage surgery was the only factory associated with prolonged survival. CONCLUSION Secondary cytoreductive surgery is a safe procedure which should be offered to recurrent ovarian cancer patients with apparently isolated and resectable disease, and without ascitis.

Do uterine fibroids affect IVF outcomes

The effect of myomectomy on implantation and pregnancy rates prior to assisted reproduction treatments is controversial. This study was designed to assess clinical outcomes of IVF cycles in women with uterine fibroids. A retrospective single-centre assessment of clinical outcomes of IVF/intracytoplasmic sperm injection (ICSI) treatments in infertile women in a 4-year span was carried out. All patients underwent detailed transvaginal ultrasound and hysteroscopy to precisely identify presence, location and intracavitary growth of uterine fibroids. Cumulative pregnancy, ongoing pregnancy and live birth rates were considered primary outcome measurements. Fifty-one women with fibroids (97 treatment cycles), 63 patients with previous myomectomy (127 cycles), and 106 infertile women who did not demonstrate fibroids anywhere in the uterus (215 cycles) were considered for the analysis. No significant difference was found for pregnancy and live birth rates between groups. Women with fibroids>4 cm required an increased number of cycles to obtain an ongoing pregnancy, compared with the other groups. The data do not support pre-IVF myomectomy in women with small-to-moderate uterine fibroids, regardless of their location. This represents valuable information in the counselling of women with fibroids before reproductive assisted cycles.

Hysteroscopic evaluation of menopausal women with endometrial thickness of 4 mm or more.

STUDY OBJECTIVE To assess the diagnostic and operative potential of hysteroscopy in postmenopausal patients selected by ultrasound criteria. DESIGN Cohort study (Canadian Task Force classification II-2). SETTING Outpatient ultrasound and hysteroscopy department of a university-affiliated hospital. PATIENTS One hundred fifty-five postmenopausal women with endometrial thickness of 4 mm or more by ultrasound, in menopause for at least 1 year, with or without menopausal complaints. INTERVENTIONS Transvaginal ultrasound and office hysteroscopy with eye-directed biopsy specimens using a 5-mm, continuous-flow, operative hysteroscope. MEASUREMENTS AND MAIN RESULTS Of the 155 women, 129 (83%) were asymptomatic (irregular bleeding). Hysteroscopy showed endometrial pathology in 28% of asymptomatic patients (23 polyps, 5 cases of hyperplasia, 8 submucous myomata) and 76% of symptomatic women (13 polyps, 6 hyperplasia, 1 submucous myoma). Hysteroscopic results compared with histologic diagnosis showed a positive predictive value equal to 97. 1% and 95% in asymptomatic and symptomatic women, respectively, and a negative predictive value equal to 100% in both groups. CONCLUSION Office hysteroscopy with endometrial biopsy samples has a diagnostic and operative role in postmenopausal patients selected based on endometrial thickness on ultrasound, in view of the high prevalence of endometrial pathology in both symptomatic and asymptomatic women.