© 2021 MJH Life Sciences and Contemporary Obstetricians and Gynecologists. all rights reserved.

© 2021 MJH Life Sciences™ and contemporary obstetricians and gynecologists. all rights reserved.

Despite its advantages, the program is still underutilized. Two experts outlined a way to get started.

Hysteroscopy is a technique that can visually assess the uterine cavity to assess structural abnormalities. Pantaleoni performed the first hysteroscopy in 1869, and since then, emerging technologies have greatly expanded the scope of the technology. 1

Improvements in hysteroscopy, optics, expansion media, anesthetics, and hysteroscopy instruments have made office hysteroscopy (OH) more feasible and less painful for patients. 2 The advantages of OH include avoiding general anesthesia, convenience for patients and doctors, faster recovery, and low cost effectiveness. 3

The cost of OH and operating room (OR) hysteroscopy has been reviewed for various indications. OH has been found to be cost-effective for assessing abnormal uterine bleeding (AUB), infertility, and intracavitary pathological shunts, ranging from negative to complex pathologies. 4-6 In a study that evaluated the cost-effectiveness assessment AUB of OH relative to hysteroscopy, it was found that the cost savings per patient was $1,498. 4 OH has also been proven to be safe and effective, with a complication rate of 0% to 1.5%. 4-6 The results of the study show that the success rate of diagnostic OH is very high, the rate is as high as 94.8%. 7

Not only has OH proven effective, but it has also been found to have high patient satisfaction in terms of comfort and convenience. 8,9

In a study of patients who underwent OH and hysteroscopic polypectomy in OR, 95% of women who received OH indicated that they would be more willing to receive OH again. It was also found that women's need for postoperative analgesia decreased, time away from home decreased, and recovery time decreased. 8

Despite these advantages, OH has not been fully utilized. In a study by Shields et al., out of 305 hysteroscopy, only about 25% were performed in the office. 6 This discrepancy may be due to limited physician training, limited availability of clinics, concerns about start-up costs, and concerns about patient discomfort.

This article will review current OH best practices and provide strategies for obstetricians and gynecologists who wish to incorporate OH into their practice.

Hysteroscopy has a wide range of diagnostic and therapeutic uses. Some of the more common uses include the diagnosis and management of abnormal uterine bleeding (AUB) and postmenopausal bleeding, including polyps, submucosal fibroids, and thickened endometrium. Importantly, OH can be used to rule out structural abnormalities to prevent unnecessary trips to the operating room.

AUB accounts for 30% of all gynecological visits by specialist obstetricians and gynecologists. 10 Diagnosis has long relied on a combination of tissue sampling and ultrasound, although their diagnostic accuracy for intracavitary pathology is low. Although transvaginal ultrasound is helpful in evaluating the myometrium, its sensitivity and specificity for evaluating intracavitary pathology are only 56% and 73%, respectively. 11

A systematic review showed that endometrial biopsy has high accuracy in assessing the overall process (such as endometrial cancer or hyperplasia), but if cancer accounts for less than 50% of the surface of the endometrial cavity, it is very likely Will be missed. 12 In the analysis to assess the accuracy of guided biopsy during hysteroscopic diagnostic hysteroscopy and hysteroscopic surgery, hysteroscopic surgery or hysterectomy, the overall success rate of diagnostic hysteroscopy was 96.6%, And abnormalities were found in 46.6% of premenopausal and postmenopausal AUB women. 13

Hysteroscopy can also be used to check for infertility, and help diagnose and treat uterine septum and Asherman syndrome. Other uses include removal of retained IUDs, targeted biopsy, diagnosis of isthmus and removal of retained contraceptive products.

Hysteroscopy has a variety of sizes, lens angles and functions. When starting an office hysteroscopy procedure, please consider which procedures will be performed. There are diagnostic hysteroscopes, which may provide a smaller outer diameter, but do not have any accessories other than inflow, and surgical hysteroscopes have larger outer sheaths, but allow scissors, graspers, graspers, and biopsy Forceps and other instruments pass.

Consider the size of instruments used in other common gynecological surgeries. For example, a typical endometrial biopsy tube is 3 mm, while an IUD insertion sheath can be 4 to 5 mm. The sizes of diagnostic and surgical hysteroscopes are as small as 2.8 and 4 mm, respectively, so these sizes can provide further comfort for doctors and patients.

The lens also has different angles. Generally, a 30° lens is a good match for a diagnostic hysteroscope because it provides the ability to observe sharp angles with little movement. The 12° lens is more compatible with surgical hysteroscopy, because the surgical equipment can be seen directly in front of the lens.

Finally, some people may consider using rigid, flexible, or disposable hysteroscopy systems. Rigid hysteroscopy allows for colposcopy and more robust surgical procedures. They usually require significant capital investment, but are more cost-effective and less wasteful than disposable systems when used frequently.

The flexible hysteroscope allows users to observe acute angles without touching the sensitive cervical wall.

However, flexible hysteroscopes usually use fiber optic cables, which are expensive to maintain, and the system is usually limited to diagnostic functions. Flexible endoscopes are usually not available for colposcopy, which is the recommended technique for pain control.

Disposable hysteroscopes provide an alternative to the high upfront cost and disinfection requirements of reusable hysteroscopes. However, the cost per use can be prohibitively high, and the plastic medical waste generated is an environmental issue. Most of them have 3 to 4 mm sheaths and have limited ability to perform surgical procedures.

When performing hysteroscopic surgery, the type of tools required must be considered. Most basic office surgeries can be done with scissors (polypectomy, adhesion lysis, metroplasty) and grasping forceps (directional biopsy, intrauterine device (IUD) removal, conception product removal).

The author prefers to add a hysteroscope gripper to completely remove large polyps by providing a stronger grip than the gripper. Although the biopsy forceps can be used for directional biopsy, the grasper can provide the same function while also being able to grasp the retained IUD.

Mechanical tissue extraction devices are also provided, whether manually or electrically operated. Some of them are paired with desktop suction devices or fluid management systems. There are also electrosurgical instruments available in the office, but the author prefers to avoid electrosurgery in the office to reduce the risk of complications, such as damage to surrounding structures and perforations.

However, if the doctor prefers energy for surgery such as hysteroplasty or hysterectomy, the 15 French bipolar resectoscope and 5 French bipolar twizzle can be used with the generator.

Hysteroscopy can be performed in a small area, such as a modified examination room (Figure 1). The examination table that can be raised and lowered is preferred. In addition to hysteroscopy, a visualization system, such as a camera, light source, and monitor, as well as the ability to capture images for electronic health records (Figure 2) is required.

Inflow and outflow pipes, operating port seals, and methods for measuring inflow and outflow are necessary. The author prefers to use a 1-L saline bag in a pressure bag for inflow, and the effluent is suspended under gravity and enters the basin or the buttocks sag. A mayonnaise stand or trolley helps to set up the equipment. In addition, if needed, speculum, cane, dilator and local anesthetic should be available. Most importantly, all reusable instruments require a cleaning process, including high-level disinfection or autoclaving in the office, or through a central aseptic processing unit.

The most widely used swelling medium in the office environment is physiological saline because it is ubiquitous and comes in a variety of bag sizes. Most office hysteroscopy settings will not use fluid management equipment because they are large and have expensive plumbing, tank costs, and waste requirements. The doctor will need a way to manually calculate the lack of fluid.

This can be performed by measuring the outflow in the hip drape or the foot basin. If the hysteroscope does not have an outflow channel, the inflow is usually very small, and there is no need to calculate the true deficit. The recommended intake of normal saline for healthy patients is limited to 2500 mL; however, for elderly patients or patients with comorbidities, a lower threshold can be considered. 14 If the doctor anticipates that the surgery performed in the office may exceed this limit, a fluid management device should be used.

When starting an office hysteroscopy plan, appropriate patient selection is the most important part of patient and doctor comfort.

A prospective cohort study showed that no childbearing, cervical pathology, and surgery of more than 2 minutes were associated with severe pain. 15 Doctors may wish to start diagnostic hysteroscopy for prolific patients without cervical pathology to build confidence in performing hysteroscopy.

Anesthesia and analgesia for office hysteroscopy have been well researched. A systematic review in 2020 found that non-steroidal anti-inflammatory drugs (NSAIDs) significantly reduced pain observed and reported during and after office hysteroscopy. Opioids and antispasmodics can reduce the pain observed during surgery, but are associated with a higher risk of adverse reactions (AE).

Therefore, women without contraindications should be advised to take oral NSAID before hysteroscopy. 16 Another meta-analysis conducted on more than 1,300 patients in 2020 showed that after pooling the data, all anesthetics have certain benefits, including local, transcervix, intracervix, paracervix and intracorneal sites 17

However, each type of anesthesia includes studies that favor placebo, and several randomized controlled trials have reported increased pain, bradycardia, and hypotension after cervical injection. 18,19 Local anesthesia does not reduce the risk of surgical failure.

The author chose to use colposcopy as the main method to relieve pain. Colposcopy involves not using a speculum or tentacles and placing the camera directly into the patient’s vagina for dilation with normal saline.

The rotating light can then guide the tilted hysteroscope along the cervical canal into the uterus. Even in difficult angles or narrow conditions, the water expansion of the canal can facilitate passage. A large study of thousands of patients over the age of 25 found that compared with traditional hysteroscopy using a speculum, the colposcopy method can reduce pain and there is no difference in the success rate of the operation. 20-22

The application of hysteroscopy in the diagnosis and treatment of intrauterine pathology: ACOG Committee Opinion, No. 800. Obstetrics and Gynecology. 2020;135(3):e138-e148. doi:10.1097/AOG.0000000000003712

AAGL promotes minimally invasive gynecology worldwide, Munro MG, Storz K, etc. AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopy Dilation Media: (Replaces the Hysteroscopy Fluid Monitoring Guidelines. 2000; 7: 167-168). J minimally invasive gynecology. 2013;20(2):137-148. doi:10.1016/j.jmig.2012.12.002

Physician fee table search. Medical Insurance and Medicaid Service Center. https://www.cms.gov/medicare/physician-fee-schedule/search

The author also does not routinely use medical cervical dilation to control pain. A meta-analysis evaluating the use of cervical preparations to reduce pain during outpatient hysteroscopy showed that premenopausal or postmenopausal women who require cervical dilation of 5 mm or less have no relief of pain, which is the largest size of our surgical hysteroscope. 23 Preoperative misoprostol can be associated with AEs, such as cramps, fever, and diarrhea, making the patient uncomfortable before the operation begins.

Finally, efforts should be made to reduce preoperative anxiety. Another meta-analysis found that pain during hysteroscopy was exacerbated by preoperative anxiety. The waiting time before surgery can increase anxiety, and music during surgery may reduce anxiety. twenty four

It is important to raise expectations with patients and let them know that the procedure can be stopped at any time. Patients who prefer to operate under sedation should be admitted to the operating room or operating center.

All patients should participate in the fully informed consent process and make an appointment when the best view of the endometrial cavity is available. Patients usually make an appointment as soon as their menstruation stops, or preferably from the 4th to the 11th day for treatment.

The considerations for starting OH in the clinic include start-up costs, reimbursement, coding, and setting up proper sterilization procedures.

In 2017, the relative value unit (RVU) of office surgical hysteroscopy (CPT code 58558) increased by 237%, while the RVUs of OR hysteroscopy cases fell by 11%. 25 These changes reflect that the payer recognizes the benefits of OH and promises to promote and incentivize its use. Depending on whether the equipment is new or old, the number of surgical trays, and the type of camera and monitor system, it is estimated that the equipment startup cost is between $15,000 and $35,000. 26,27 As reimbursements increase, doctors and practitioners have the potential to break even with less than 50 office surgeries and hysteroscopy.

Various models have been designed for hysteroscopy simulation, but there are limited studies on clinical utility and results. 28 models include animal organs, vegetables, synthetic uterus and virtual reality.

The American College of Obstetrics and Gynecology (ACOG) has designed a hysteroscopy simulation module for resident education. The module uses synthetic uterine models and plant models to improve skills and knowledge, including hysteroscopy assembly and hysteroscopy and surgery. Capability 29 Virtual models, including HystSim (VirtaMed), have become more realistic and allow a series of procedures, but require further verification before being included in a standardized curriculum.

Hysteroscopy can be performed safely in the office, with high efficacy and high patient satisfaction; however, the incidence of OH in the United States is still very low. In addition, OH has been found to be cost-effective, and the reimbursement rate for OH doctors has increased compared to hysteroscopy in OR. The setup should be relatively simple and requires communication with clinic staff to ensure that the patient is comfortable and the equipment can be used and disinfected.

Considering the benefits to doctors and patients, OH should be regarded as a first-line choice for the diagnosis and treatment of various uterine pathologies.

OH can also be used to classify cases, prevent negative cases from entering the operating room, and ensure that more complex pathological examinations can be completed in an appropriate environment.