V.V. Khvalov, L.N. Khvalova

The 8 year experience of performing ambulatory fibrohysteroscopy at the Endoscopy department of Severstahl General Hospital.

The Endoscopy Department of Severstahl Medical Service has been performing ambulatory fibrohysteroscopy since February 2000 . The Department has flexible Pentax, Olympus and Karl-Storz hysteroscops at its disposal. The external diameter of diagnostical hysteroscope is 3,1 and 3,5mm with the instrumentally canal diameter of 1,2mm. The operative hysteroscopes have external diameter of 4,9mm and instrumentary canal diameter of 2,2mm. 2350 hysteroscopies were done during the 8 years of work. Operative hysteroscopy is being done since 2002. We performed 380 of the procedures during that period of time. The tissue specimens were taken 1530 times (66% of all procedures). We performed 300-400 hysteroscopies (including 50 operative ones ) each year for the last 5 years. Ambulatory flexible hysteroscopy is now a routine procedure at the Endoscopy Department as well as esophagoduodenoscopy, colonoscopy, bronchoscopy and retrograde cholangiopancreography. During the 8 years of work we have done 870 hysteroscopies in women of reproductive age (between 18 and 40 years) which is 38% of all the procedures done. The catheterization of the proximal part of fallopian tubes was performed 122 times. We have done 80 operative hysteroscopies in women or reproductive age within the last 6 years. Electro excision of endometrial polyps was performed 37 times. The cervical canal polyps were removed 28 times. Intrauterine adhesions were cut 8 times. We also used hysteroscope and other endoscopy equipment to extract intrauterine contraceptive (4 times). Within the last 6 years 75 infertile patients got pregnant or gave birth to children after being performed a hysteroscopy. 60 infertile women were planned a certain treatment management. Hysteroscopy is useful in a number of uterine conditions:

Hysteroscopy together with the other diagnostical and curative measures helps women to conceive and make the periods regular .

Diagnostical and operative hysteroscopies have the following benefits :

Ambulatory flexible hysteroscopy (both diagnostical and operative) is in high demand nowadays due to the high rate of intrauterine pathology and the obvious benefits of this method. So the obstetrisians –gynecologists send their patients more and more often to this almost non-invasive procedures which help women without affecting their quality of life.

 

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V.V. Khvalov, L.N. Khvalova

ONE THOUSAND AND ONE AMBULATORY HYSTEROSCOPY. FIVE YEAR EXPERIENCE. "Severstahl Medical Service" , Cherepovets, Vologda region, Russia 2004.

Hysteroscopy is the only method that allows with the optical system of endoscope for the inspection of the womb including the detailed diagnosis of intrauterine pathology and checking the therapy results. It is now a common diagnostical and curative procedure which is widely used in gynecology. The invention of fibrohysteroscope – a flexible hysteroscope with fiberoptics- gave a start to the development of ambulatory hysteroscopy at the end of the 20 century. Modern hysteroscopes are so thin that they can fit through the cervix without any dilation. They can penetrate 1 - 50 mm inside the womb. The distal end of fibrohysteroscope is so flexible that it can turn around 100 degrees. It is important to diagnose a patient before her hospitalization so the development of new techniques and approaches in performing modern office hysteroscopy is absolutely necessary. This necessity is confirmed by the Heath Service Ministry orders. For example the Instruction N323 (05.11.98) defines medical standards of inspection and treatment in obstetrics, gynecology and neonatology. N 06/13 (26.03.98) deals with family planning. These documents pay special attention to hysteroscopy as a diagnostic measure in adult and childhood gynecology and also as the curative measure in the cases of complications after using contraceptives and during abortions. The Health Care Ministry Instruction N222 (13.05.96) “ The Improvement of Endoscopy Service in Medical Institutions of the Russian Federation” defines hysteroscopy as the obligatory procedure at the Endoscopy Departments in hospitals and other medical services. So the gynecologists and endoscopists of Severstahl Medical Service keeping in pace with the modern tendencies and under the approval of the Hospital authorities decided to unite their efforts to introduce ambulatory hysteroscopy into the practical work of the hospital. During the study period which took us 2 years we did the following:

Endoscopy Department of Severstahl Medical Service has been performing hysteroscopy since February 2000. At first only diagnostical hysteroscopies were performed. Then, several months later we started to do easy curative procedures. While mastering the new technique two doctors were present at the examination of the patient: an antenatal clinic gynecologist and a physician-endoscopist. After the experience being gathered and the more up-to-date equipment being bought it has become possible for the physician-endoscopist to work all by himself. Now the two of the doctors perform only difficult operative procedures. The combined use of hysteroscopy and echography allows to reveal the intrauterine pathology more accurately because the echography is a noninvasive , comparatively simple and highly informative technique.

Indications

ГHysteroscopy is an invasive technique so if prescribed a specimen should be taken for a cytomorpholohical examination.

Contraindications

The Endoscopy Department of Severstal Medical Service has fibrohysteroscopes with the diameter of 2,5mm, 3,5mm and 4,9mm.Their instrumentally canal diameter is 1,2 and 2,2mm. Since 2001 the physician is watching the procedure on the monitor. The videotape recorder gives the opportunity to record hysteroscopy. Ambulatory hysteroscopies are done at the endoscopy room which is equipped according to the hygenical requirements. The sterilization of hysteroscope and other equipment is done in sterilization room immediately before the procedure.

For the last 5 years 1000 procedures have been done at the department. Their number increased from 54 hysteroscopies in 2000 to 350 hysteroscopies in 2003. The annual growth of medical hysteroscopies increases in figures as well as in their percentage. The removal of the polyps of the body of the uterus and cervix made up 73% of all surgical interventions 5% of which were the mechanical removal of polyps with biopsy forceps , 68% of polyps were removed by electro excision and diathermocoagulation . Electro excisions of cervical polyps were performed more often. They account for 34% of all medical interventions. Electro excision of polyps of the body of the womb takes the second place which accounts for 24% of all medical hysteroscopies (29 electroexcisions in figures). In 10% (12 cases) polyps of the body of the womb were removed together with cervical polyps by high frequency current. The flexible 4,9mm diameter endoscope with instrumental canal of 2,2mm was used in that case. We also use electro excision loops and electrosurgical set PSD-10 Olympas, Japan. 5% glucose solution was used as a distention medium. The polyps were from small (o,5mm in diameter and height ) to middle (2-3cm height and 1-1,5cm in diameter). It was not always possible to remove polyps of middle size because of the high uterine tension. In one case the polyp was removed some days later during the hysteroscopy with the tripod clamp and in three other cases the polyp went away by itself. According to histological examination the removed polyps were glandular, fibro glandular and fibrous. Intrauterine devices ( contraceptives) were removed from the uterine cavity and cervix 14 times which makes up 11% of all medical interventions. In 4 cases it was done by the extractor under the hysteroscopy control . In 10 cases intrauterine devices were removed through the channel of hysteroscope. Indications for the removal of a contraceptive by hysteroscope were the tearing off their ligatures and “forgotten” spirals found during ultrasound examination. 12 procedures (10% of their total number) were devoted to the cutting of adhesions. In 5 cases the adhesions in fallopian tubes were separated with the hysteroscope and endoscopy equipment In 4 cases adhesions of the body of the womb were destroyed using the end of hysteroscope and in one case electro excision was performed. Cervix adhesions in state of incomplete atresia were cut 2 times with hysteroscope and Gegard dilator. Foreign bodies were removed from the womb 2 times (LAMINARIA RODS). Diathermocoagulation and incomplete electro excision of cervix fibromioma were performed 2 times. NABOTOV cyst in cervical canal was removed once using diathermocoagulation. Electroexcision and diathermocoagulation in postoperative scar of vaginal cupola were also performed once.

CONCLUSIONS

Medical outpatient hysteroscopy has following benefits:

Time shows that outpatient hysteroscopy (both diagnostic and medical) is in great demand. Obstetrician-gynecologists from outpatient and inpatient facilities more and more often prescribe to their patients this almost noninvasive procedure which helps women without affecting their quality of life.

CONCLUSIONS

THE LIST of the USED LITERATURE