Steven J. Milim

The effect of dilute vasopressin solution on blood loss during operative hysteroscopy: A randomized controlled trial

Objective To assess the effect of intracervical injection of dilute (0.05 U/mL) vasopressin solution on blood loss during operative hysteroscopy. Methods In a randomized, double-blind study, dilute vasopressin solution or placebo (normal saline) was injected into the cervical stroma of 106 women before dilation of the cervix in preparation for operative hysteroscopy. Intraoperative bleeding was calculated by dividing the number of red blood cells per milliliter of outflow distention fluid by the number of red blood cells per milliliter of the womans blood immediately before the procedure and multiplying this quotient by the total amount of outflow fluid collected. Pressures were kept constant with a hysteroscopic infusion pump. Results The mean (± standard error of the mean) intraoperative blood loss of the treated (vasopressin) and control (placebo) groups was 20.3 ± 4.1 mL (range 0–135) and 33.4 ± 5.4 ml, (range 0–290), respectively. The volume of distention fluid intravasation in the treated and control groups was 448.5 ± 47.0 ml, (range 30–1410) and 819.1 ± 79.7 mL (range 20–1977), respectively. The operating time in the treated and control groups was 31.1 ± 1.2 minutes (range 18–52) and 34.1 ± 1.3 minutes (range 19–65), respectively. For all three outcome measures, the differences between the two groups were statistically significant, but for visual clarity of the uterine cavity during surgery, the difference was not significant. Conclusion Administration of dilute vasopressin solution (0.05 U/mL) to the cervical stroma significantly reduces blood loss, distention fluid intravasation, and operative time during hysteroscopy. Further evaluation is required to determine the optimum dosage.

Laparoscopic bipolar coagulation for the conservative treatment of adenomyomata

STUDY OBJECTIVE To assess the effectiveness of treating adenomyomata with laparoscopic bipolar coagulation. DESIGN Prospective, observational study. Setting. The gynecology department of a community hospital. PATIENTS Ten women, each with severe dysmenorrhea, chronic menorrhagia, and adenomyomata diagnosed by magnetic resonance imaging. INTERVENTIONS Laparoscopic bipolar coagulation of adenomyomata. MEASUREMENTS AND MAIN RESULTS The mean (+/- SEM) total adenomyoma volume before leuprolide acetate administration was 119 +/- 16 cm3 (range 6-190 cm3); after 3 months of therapy this was reduced to 86 +/- 8 cm3 (range 6-162 cm3, p <0. 0001) a 27.7% reduction. Further reduction occurred 7 to 12 months postoperatively to 31 +/- 3.4 cm3 (range 3-155 cm3, p <0.0001), a 73.9% reduction from baseline. Twelve months postoperatively, seven (70.0%, p <0.05) women had continued resolution or significant reduction of dysmenorrhea and resolution of menorrhagia. One woman (10.0%) with unresolved dysmenorrhea and menorrhagia required hysterectomy, and two (20.0%) with recurrent menorrhagia required resection of the endomyometrium; one continued to have menorrhagia but refused further surgical or medical treatment. CONCLUSIONS Conservative treatment obviated the need for major surgery in 90% of women with adenomyomata, but further evaluation of this technique is necessary to determine its definitive role.

Preventing hyponatremic encephalopathy: Comparison of serum sodium and osmolality during operative hysteroscopy with 5.0% mannitol and 1.5% glycine distention media

STUDY OBJECTIVE To determine whether isotonic 5.0% mannitol is superior to 1.5% glycine in preventing development of hyponatremic encephalopathy. DESIGN Prospective, comparative study (Canadian Task Force classification II=2). SETTING Gynecology department of a community hospital. PATIENTS One hundred twenty-two women undergoing operative hysteroscopy. INTERVENTIONS Eighteen blood serum chemical indicators analyzed preoperatively and postoperatively in 61 women undergoing operative hysteroscopy with 1. 5% glycine (group 1) were compared with those of 61 women having similar surgery with 5.0% mannitol (group 2). Fluid deficit (difference between input and output volume of distention fluid) was recorded, and differences between presurgical and postsurgical indicators of the two groups (mean difference score) were compared. MEASUREMENTS AND MAIN RESULTS Mean +/- SEM sodium difference scores of groups 1 and 2 were -1.73 +/- 0.42 mEq/L (range -7.00 to 2.00 mEq/L) and -5.04 +/- 1.07 mEq/L (range -36.00 to 3.00 mEq/L), respectively (p <0.01). Serum osmolality difference scores were -6. 88 +/- 1.36 mmol/L (range -13.00 to -1.00 mmol/L) and -1.87 +/- 0.35 mmol/L (range -3 to 15 mmol/L), respectively (p <0.01). Distention fluid deficits were 0.435 +/- 0.071 L (range 0-2.448 L) and 0.473 +/- 0.084 L (range 0-3.640 L), respectively (p = 0.862). Two women (3.4%) in group 1 and five (8.2%) in group 2 developed postoperative asymptomatic dilutional hyponatremia (p = 0.211), which was the only complication. Two of the five women in group 2 developed severe dilutional hyponatremia. CONCLUSION We found that 5.0% mannitol distention fluid produces greater postoperative dilutional hyponatremia than 1.5% glycine, but hypo-osmolality does not occur with mannitol. Its use should lessen the risk of hyponatremic encephalopathy.

100 laparoscopic hysterectomies in private practice and visiting professorship programs

STUDY OBJECTIVE To evaluate 100 laparoscopic hysterectomies and their variations in private practice and visiting professorship programs. DESIGN A prospective observational study. SETTING Gynecology departments of 17 teaching, community, and proprietary hospitals in the northeastern United States. PATIENTS One hundred women who successfully underwent laparoscopic hysterectomy, 91 of whom were followed for 6 months. INTERVENTIONS From July 1990 to August 1994, 108 women (mean age 41.6 yrs, range 38-68 yrs) for whom a vaginal hysterectomy was relatively contraindicated underwent a hysterectomy attempted by the laparoscopic route. The most common indications for hysterectomy were pelvic pain, chronic menorrhagia, and uterine leiomyomas. The women were classified according to hysterectomy, with groups comparable in age, weight, uterine size and weight, concomitant surgery performed, uterine and coexisting pathology, and history of pelvic surgery. Of the 108 women, 35 had laparoscopic hysterectomies (LH), 56 had laparoscopic-assisted vaginal hysterectomies (LAVH), and 9 had subtotal laparoscopic hysterectomies (SLH). Eight procedures were converted to laparotomy, two attempted LHs and six attempted LAVHs. In 22 cases, bipolar coagulation of vascular pedicles was done exclusively, in 58 the Endo GIA 30 stapler was used exclusively, and in 20 a combination of both modalities was used. Bilateral ureteral catheters were inserted 49 times. MEASUREMENTS AND MAIN RESULTS There were eight complications (8.0%): two blood transfusions, two cases of transient, asymptomatic pyrexia, two abdominal wall hematomas, one Richter hernia, and one urinary tract infection. The hernia repair was the only delayed laparotomy. The mean (+/-SEM) surgical time was 123 +/- 8 minutes (range 45-235 min), and the mean hospital stay was 1.48 days +/- 0.4 (range 1-5 days). Ninety-five of the 100 women who successfully underwent a laparoscopic procedure returned to work within 2 weeks (range 4-14 days, range 15-53 days for the remaining 5). CONCLUSION Hysterectomy performed or aided by the laparoscope, whether LH, LAVH, or SLH, is effective and safe as long as at least one member of the surgical team is an experienced and appropriately trained laparoscopic surgeon. Further studies are necessary to determine if the credentialing process for advanced laparoscopic surgery would be facilitated by a visiting professorship program.

Laparoscopic leiomyoma coagulation

From February 1992 through March 1995, 167 women (mean ± SEM age 44.7 ± 0.3 yrs, range 22-52 yrs) with symptomatic leiomyomata underwent laparoscopic leiomyoma bipolar coagulation. Women with chronic menorrhagia had concomitant transcervical endometrial resection (TEMR) and resection of any existing submucous leiomyomas (TSR). Follow-up was 30.2 ± 1.0 months (range 12-49 mo). Depot leuprolide acetate was administered for 3 months before surgery to 164 (98.2%) of the patients. The surgical procedure was evaluated in terms of numbers and types of concomitant procedures, whether or not symptoms were controlled, and changes in uterine and leiomyomata volumes. Mean total uterine volume decreased from 623 cm3 before leuprolide treatment to 139 cm3, a 77.7% reduction, 7 to 12 months postoperatively (p <0.0001). Six women (3.6%) had hysterectomy for recurrent menorrhagia, pain, and pressure; pathologic evaluation revealed adenomyosis or leiomyomata or both. Of 52 women with chronic menorrhagia, 33 (63.5%) developed amenorrhea, 17 (32.7%) had hypomenorrhea or eumenorrhea, and 2 (3.8%) required repeat TEMR. The two women who desired fertility had uncomplicated viable full-term pregnancies and delivered vaginally. Laparoscopic myolysis alone or in conjunction with TEMR and TSR obviated the need for major surgery in 161 patients (96.4%). Until further studies are concluded, only selected women contemplating pregnancy should undergo myolysis.

The effect of dilute vasopression solution on blood loss during operative hysteroscopy

A study was designed to assess the effect of intracervical injection of dilute vasopressin solution 0.05 U/ml on intraoperative blood loss during operative hysteroscopy. In a prospective, computer-randomized, double-blind study, vasopressin or placebo (normal saline) was injected into the cervical stroma of 108 women before dilatation of the cervix. Intraoperative bleeding was calculated by dividing the number of red blood cells/milliliter of outflow distention fluid by the number of red blood cells/milliliter of the patients blood immediately before the procedure, and multiplying this quotient by the total amount of outflow fluid collected. Mean (± SEM) intraoperative blood loss of the placebo-treated group was 35 ± 6.5 ml (range 0-290 ml), and in the vasopressin-treated group was 18.2 ± 3.8 ml (range 0-135 ml), a 47.1% reduction (p <0.001). The visual clarity of the uterine cavity during surgery was not statistically different in the two groups. The concentration of vasopressin 50 U/ml may prove to be clinically significant to minimize the risk of cardiovascular morbidity, especially in women who are severely anemic and at risk for blood transfusion.

Relationship of endometrial thickness with the menstrual timing of leuprolide acetate administration for preoperative preparation for hysteroscopic surgery.

STUDY OBJECTIVES To assess the relationship of menstrual timing of administration of gonadotropin-releasing hormone (GnRH) agonist on the effectiveness of endometrial thinning and unwanted uterine bleeding. DESIGN Prospective observational study. SETTING Gynecology department of a community hospital. PATIENTS One hundred consecutive women in a private practice, without submucous myomas, scheduled for transcervical endomyometrial resection or ablation. INTERVENTIONS A GnRH agonist was administered at an unspecified time of the menstrual cycle. Transcervical hysteroscopic endomyometrial resection or ablation was performed 1 month later. MEASUREMENTS AND MAIN RESULTS No significant statistical differences were seen in either the effectiveness of endometrial thinning or the occurrence or severity of unwanted uterine bleeding. CONCLUSIONS A GnRH agonist as pretreatment for endomyometrial resection or ablation can be administered at any time during the menstrual cycle with similar efficacy. Timing of surgery can be at the mutual convenience of patient and physician.

The effect of dilute 0.25% vasopressin solution on the linear force necessary for cervical dilatation

We assessed the force necessary for mechanical cervical dilatation on a nonpregnant uterus after intracervical administration of dilute vasopressin solution 0.05 U/ml. In a prospective, double-blind, randomized study, vasopressin or placebo was injected into the cervical stroma before dilating the cervix in preparation for resectoscopy. An electronic load cell was used to measure the peak linear force necessary to dilate the cervix from 3 to 11 mm using half-size metal dilators. Mean (± SEM) total peak linear force to dilate the placebo-treated cervix from 3 to 11 cm was 36.82 ± 1.88 lbs (range 6.11-52.2 lbs). In the vasopressin group it was 20.57 ± 5.54 lbs (range 5.54-40.82 lbs, p <0.001), a 44.1% reduction. One cervix (3.8%) in the placebo group and one (3.6%) in the vasopressin group required suturing of lacerations (p >0.05). This effect of dilute vasopressin solution may reduce trauma to the internal cervical os and lower uterine segment.