CHAPTER 2 Hysteroscopy
Introduction
Over the last century, uterine surgery has evolved from being dominated by hysterectomy to a range of less invasive procedures that have the common principle of conserving the uterus and reducing procedural morbidity. Disorders of the uterine cavity leading to abnormal uterine bleeding, infertility and pain affect the majority of women during their lifetime. The ability to view the uterine cavity has enabled the accurate diagnosis and treatment of numerous conditions. The quest to improve diagnostic and therapeutic capabilities has led to the widespread acceptance of modern gynaecological endoscopy.
Historical Development
Bozzini was the first to look into the cavity of a hollow organ, the bladder, in 1805. This was achieved with long tubes assisted by external illumination. In 1853, Desormeaux made the first satisfactory endoscope, but it was Panteleoni who performed the first satisfactory hysteroscopy in 1869 (Panteleoni 1869). Inability to distend the uterus and lack of proper illumination caused poor visualization and lack of widespread acceptance until Lindemann renewed Rubin’s attempts to use carbon dioxide in the 1970s (Lindemann 1972).
Diagnostic Indications
Abnormal uterine bleeding
Menstrual abnormality is one of the most common reasons for referral to the gynaecological outpatient department. Menometrorrhagia, dysmenorrhoea and intermenstrual bleeding are the most common. After the menarche, such problems are usually dysfunctional, and hysteroscopy is rarely indicated. In postmenopausal patients, bleeding is a worrying symptom and warrants urgent attention as the patient is anxious to exclude endometrial cancer. Outpatient hysteroscopy offers rapid diagnosis and reassurance. In women of reproductive age, abnormal uterine bleeding can be associated with hormonal disturbances or pathology such as fibroids and polyps. Cervical polyps may be associated with endometrial polyps in 26.7% of patients (Stamatellos et al 2007), and exclusion of endometrial pathology is important.
Infertility
Hysteroscopy is a reliable method to detect and potentially treat submucous fibroids, endometrial polyps, intrauterine adhesions and endometritis. Congenital anomalies are infrequent but are associated with infertility. Abnormalities of the endometrium and organic intrauterine pathologies are important causes of failed in-vitro fertilization/embryo transfer cycles. A recent meta-analysis has shown potential benefits of performing pretreatment hysteroscopy in patients being referred for IVF (El-Toukhy et al 2008).
Intrauterine synechiae (Asherman’s syndrome)
Intrauterine adhesions can lead to infertility, recurrent miscarriage, hypomenorrhoea or amenorrhoea. Adhesions are caused by trauma to the endometrial basal layer, during evacuation of retained products of conception or may be secondary to infections (e.g. tuberculosis).
Fibroids and polyps
Submucus fibroids and polyps, which occlude the cervix or the tubal ostia, may hamper sperm progression and interfere with implantation.
Müllerian anomalies
Patients with a uterine structural anomaly may have normal fertility or present with infertility. Hysteroscopy may reveal arcuate, subseptate, septate, bicornuate or uterus didelphis. Hysterosalpingography, ultrasonography and laparoscopy are additional valuable tools to investigate these patients once an anomaly has been found.
Recurrent miscarriage
The aetiology of recurrent miscarriage is poorly understood. Intrauterine pathology such as fibroids, polyps, Asherman’s syndrome or congenital abnormalities may be detected in up to 33% of infertile couples (Romano et al 1994). Implantation of an embryo over the septum or fibroid can also fail due to the poor blood supply in these parts of the uterus.
Foreign body
Missing threads of an intrauterine contraceptive device (IUCD) or a deeply embedded coil may need to be removed under hysteroscopic guidance. Apart from anxiety, these patients may present with menstrual irregularities and pain.
Chronic pelvic pain
Patients with chronic pain can pose a difficult challenge to the gynaecologist. Obstructive uterine anomaly may be associated in 40% of these patients (Schifrin et al 1973). Concomitant hysteroscopy may reveal polyps, fibroids, adhesions and septate uterus which may contribute to the patient’s symptoms.
Contraindications
Infection
Hysteroscopy in the presence of acute pelvic infection can lead to spread of infection with the distension medium flowing through the tubes, spreading the infection to the peritoneal cavity. The only exception is when infection is secondary to a lost IUCD, which should be removed hysteroscopically under antibiotic cover.
Pregnancy
Pregnancy is another contraindication, although embryoscopy prior to 10 weeks of gestation has been performed as an aid to prenatal diagnosis. Pregnancy leads to increased uterine softening and vascularity, increasing the risks of bleeding, uterine perforation and miscarriage. Hysteroscopy during pregnancy may occasionally be performed to remove a coil where the tails are not visible.
Malignancy
Hysteroscopy is contraindicated in the presence of cervical cancer. However, it is a gold standard procedure in patients with endometrial cancer as it aids directed biopsy.
Bleeding
Diagnostic hysteroscopy may be performed in the presence of bleeding, but the view is likely to be poor. Hysteroscopy is best performed in the mid-to-late proliferative phase when the endometrium is thinnest. If this is difficult to arrange, preoperative hormonal treatment with progesterone can help to postpone or control bleeding.
Cardiopulmonary disorders
Patients with these medical conditions are at higher risk of anaesthetic when recognized hysteroscopic complications, such as gas embolism and fluid overload, occur. Outpatient hysteroscopy under local anaesthetic is therefore the treatment of choice for such patients.
Cervical stenosis
Patients who have a history of cervical surgery or difficult uterine entry in the past are at increased risk of cervical trauma, perforation and false passage during the performance of a hysteroscopy. Prostaglandins inserted 2 h before hysteroscopy may help to soften the cervix, allowing easy dilatation and entry into the uterine cavity, although the evidence is limited for their value in postmenopausal patients (Crane and Healey 2006).
Instrumentation
Inadequate instrumentation resulting in poor visualization and reduced safety is not only dangerous, but will potentially give erroneous results. Good-quality hysteroscopes, cameras and driver units are basic requirements for good visualization of the uterine cavity. Appropriate fluid monitoring systems and energy sources, such as laser or diathermy, are essential for operative hysteroscopy (Figure 2.1).
Figure 2.1 Clinical anatomy of the uterus, showing the relation between the angle of the telescope, the light lead and the camera orientation.
Before commencing any hysteroscopic procedure, one must ensure that the stack system (Figure 2.2) is fully functional. This includes the telescope, surgical instruments, camera drive unit, camera head, light source, light lead, monitor, electrosurgical generator and image recording equipment. If a simultaneous laparoscopy is required, two stack systems should be made available. It is essential to assemble the equipment to ensure that it works prior to use. The distension medium, suction machine, fluid measurement apparatus and connecting tubing must be checked. Fluid should be allowed to flow through the giving set to remove all air bubbles.
Optical systems
Rigid telescopes
Panoramic hysteroscopy is performed with the help of a distension medium, and is common practice. The majority of hysteroscopists use rigid telescopes. Improved technology has allowed significant reduction in the outer diameter (as low as 2.5 mm, including the inflow sheath). The outer diameter of operative hysteroscopes using monopolar electrosurgery may be up to 10 mm. This includes the telescope with the working element, inflow sheath (inner) and outflow sheath (outer). Smaller-diameter operative scopes (Figure 2.3) measure 5 mm and consist of a 5 French operative channel communicating with the outflow sheath. This allows instruments of 5F diameter (e.g. the bipolar electrode, laser fibre, mechanical scissors and grasper) down the operative channel. The telescopes may be forward view (0°) or oblique view (angled scopes 12, 30, 70 or 90°).
Flexible telescopes
Flexible hysteroscopes offer the advantage of negotiating the scope along the uterine cavity with a ‘no touch technique’. The tip can bend up to 110°, allowing easy uterine entry with minimal discomfort. Improved optics helps the image quality to be comparable with small rigid scopes. The risk of uterine perforation is reduced as the scope is able to negotiate the angle between the cervix and the uterus. The disadvantage is that continuous flow irrigation is not currently available for flexible hysteroscopy.
Hysteroscopic sheaths
For diagnostic panoramic hysteroscopy, a single sheath for inflow is sufficient. This enables a smaller outer diameter and outpatient hysteroscopy without anaesthesia. Operative hysteroscopy needs separate sheaths for inflow and outflow. The inflow sheath carries the distension medium to the tip of the telescope, from where it is withdrawn via the outer sheath (Figure 2.4). Fluid circulates over the tip of the telescope to maintain a clear view.
Camera and stack system
The hysteroscopic image is visualized on a monitor with the help of a camera connected to a camera drive unit. The image clarity of a single chip camera is perfectly adequate. Special weighted cameras are available and facilitate orientation, but the same camera as is used for laparoscopy is equally appropriate. It is important to ‘white balance’ the camera system to ensure that the colours are displayed correctly (see Figure 2.2).
Light source
A minimum power of 150 W is essential to obtain a clear image. It is essential to have a spare bulb and to know how to change it, as it can fail in the middle of a procedure. After use and between cases, if the light source is not going to be used for a short while, the bulb intensity should be turned down. Switching the light source on and off frequently reduces the bulb life.
Light lead
The optic fibres running along the light lead need careful handling and should never be rolled or kinked as the fibres break. Damaged fibres do not transmit light from the source, and give rise to poor illumination. The light lead should be checked before starting any procedure.
Monitor
The wiring and controls of the camera drive unit are often complex. The hysteroscopist should be familiar with the setting up of the system and able to rectify simple faults. One should always check that the monitor is displaying the appropriate image before commencing the procedure.
Image recording equipment
Images taken before and after the procedure can help patients to understand their clinical condition, and allow comparison with images obtained at a later date. Recorded images can serve as evidence in defence if there is a claim of medical negligence against the surgeon. Recordings of various hysteroscopic procedures can become useful teaching aids for trainees.
Distension medium
The anterior and posterior uterine walls are in apposition. In order to obtain a view, the uterine cavity has to be distended with gas or fluid. Carbon dioxide can be effective for diagnosis, and is delivered via a pressure reduction system or hysteroflator which is designed to give a maximum flow rate of 100 ml/min and a maximum pressure of 200 mmHg (note: a laproflator must not be used). An alternative is to use a liquid distension medium (e.g. normal saline or Hartmann’s solution) which is appropriate for diagnosis and some operative procedures. Monopolar electrosurgery requires a non-conductive distension medium such as 1.5% glycine. However, it should be remembered that once the solution becomes contaminated with blood, its function as an insulator is reduced. Fluid can be pressurized via a roller pump (with maximum flow rate of 500 ml/min and maximum pressure of 200 mmHg), gravity or a pressure infusion bag cuff system. For diagnosis, gravity or a 50-ml syringe connected to a giving set via a three-way tap provides very good control of the distension pressure. Dextran 70 (Hyskon) is no longer used due to anaphylactic reactions.
Technique of Diagnostic Hysteroscopy
Clinical anatomy of the uterus
The uterine cavity is flat in its anterior/posterior dimension as, when not distended, the anterior and posterior endometrial surfaces are apposed to each other. The cervical canal is essentially round, but once the cavity is entered, the lateral dimension widens until it is at its broadest at the fundus. The cavity extends laterally towards the tubal ostia (see Figure 2.1). The fundal dome may be flat, concave or convex on its interior surface. Indeed, a proportion of uteri have a pronounced fundal convexity, a so-called ‘arcuate deformity’.
Endometrial preparation
A diagnostic hysteroscopic examination is best performed without medical preparation of the endometrium. The endometrium will be at its thinnest in the immediate postmenstrual phase, and at its most vascular in the premenstrual phase. Abnormal bleeding is a common indication for diagnostic hysteroscopy, and whilst it is often possible to time the examination such that bleeding is not occurring, light bleeding need not preclude successful examination of the endometrial cavity. When prolonged heavy bleeding occurs, norethisterone 5 mg three times daily for 7–10 days may be given prior to the examination. It is rarely necessary to use a gonadotrophin-releasing hormone (GnRH) analogue prior to a diagnostic procedure, but one to three doses are employed prior to endometrial ablation, or to shrink a vascular fibroid prior to operative hysteroscopic resection.
Anaesthesia
In the majority of cases, the smallest modern diagnostic hysteroscopes require no anaesthetic whatsoever. A crucial factor is good communication between the gynaecologist and the patient, with thorough preoperative counselling and the support of a skilled nurse who is able to complement the operator in explaining things to the patient. The role of local anaesthetic gels is open to question. They are inexpensive and certainly lubricate and cause the external os to open. They probably have little anaesthetic effect other than as a psychological adjunct to the gynaecologist’s reassurance.
Where facilities do not exist for outpatient hysteroscopy, the procedure is carried out in the operating theatre. Whilst a 5-mm rigid diagnostic hysteroscope can be passed through the cervix in the majority of women of reproductive age, this can prove extremely difficult in postmenopausal women and cervical dilatation is often needed. This requires a paracervical block, a regional anaesthetic or a general anaesthetic. The choice of anaesthetic method will, of course, be decided in conjunction with the anaesthetist and the patient. The choice will, in part, be determined by the patient’s state of health and whether any additional procedures are planned. It must be remembered, however, that those patients who are at risk of endometrial cancer in the postmenopausal period are often more obese and suffer from cardiovascular and airways disease. These render them at high risk from the anaesthetic point of view. Such patients provided a major stimulus to the establishment of outpatient diagnostic and, in some cases, therapeutic hysteroscopy services.
Positioning
Hysteroscopy can be performed on a general operating table equipped with lithotomy poles or Lloyd Davies supports. Care must be taken to avoid excessive pressure from the leg supports on neurovascular structures, and if there is limitation of joint movement owing to hip or knee pathology, the final position of the patient will have to be modified.
In the outpatient setting, a colposcopy chair is desirable. This allows a comfortable modified lithotomy position with minimum loss of dignity. It is essential that the patient should be kept covered until the examination is due to start.
Procedure
Inpatient/general anaesthetic
A pelvic examination is performed in order to determine the size and direction of the uterus. The vulva and vagina are cleaned with antiseptic solution, and the anterior lip of the cervix is grasped with a vulsellum forceps. The majority of rigid hysteroscopes offer a fore/oblique view ranging from 12 to 90°. By convention, the direction of the view is away from the light post. The camera system is attached to the scope with the camera orientated correctly and the light post either up or down such that the angled view is in the vertical plane. It is easier to follow the cervical canal if the scope is orientated to view along the direction of the canal (i.e. forwards and downwards in a retroverted retroflexed uterus). Crucial to obtaining a thorough hysteroscopic examination is an understanding of how rotation of the hysteroscope allows the area of uterine wall under inspection to be changed. The authors suggest holding the camera in one hand and maintaining the position of the camera fixed in relation to the vertical plane. Rotation of the scope by manipulating the light post with the other hand allows the view to be manipulated appropriately.
Insertion of the hysteroscope through the cervical canal should be performed under direct vision and, in the first instance, without cervical dilatation or the passage of a sound. This allows examination of the cervical canal and inspection of undamaged endometrium. Once instruments have been passed into the uterine cavity, they cause damage to and stripping of the endometrium, which can then give appearances suggestive of polyp formation. The image of the cervical canal during passage of the scope is, of course, dependent on the viewing angle of the scope. A 0° scope requires the cervical canal to be kept in the middle of the field of view during insertion to maintain the direction of travel of the scope parallel to the direction of the cervical canal. When an angled viewing scope is used, the position of the cervical canal in the field of view has to be offset in order to maintain the direction of travel of the hysteroscope parallel with the direction of the cervical canal. This is why orientation of the light post relative to the orientation of the camera is a crucial step in the assembly of the equipment, but it is often overlooked.
Once the cervical canal is passed, a panoramic view of the uterine cavity is obtained. Uterine distension at a flow rate of 40–60 cc/min with pressure between 40 and 80 mmHg achieves good visualization. The scope is advanced towards the fundus and rotated to allow inspection of the tubal ostia. The scope can then be withdrawn and readvanced whilst rotating it to enable systematic inspection of each uterine wall in turn.
Potential problems include blood accumulating in the cavity and obscuring the view. This can occur during diagnosis when the seal between the hysteroscope and the cervix is very tight, preventing outflow of distension medium. The passage of a dilator 1 mm greater than the outer diameter of the hysteroscope allows flow and clearance of the contaminating blood. If a large polyp is present in the endometrial cavity, it is possible to inspect the cavity without realizing that the polyp is there because the polyp fills the cavity and the scope has been passed beyond the tip of the polyp before inspection begins (Figure 2.5). Suspicion should be aroused if the endometrial surfaces are different in colour, and careful inspection of the panoramic view of the cavity during insertion and removal of the scope will avoid missing a large polyp as the tip of it will be seen. A thorough examination of the uterine cavity should allow inspection of both tubal ostia. A record of this in the operation notes demonstrates that the operator has obtained a good view.
Postoperative care
The majority of the recovery process after a diagnostic hysteroscopy relates to recovery from the anaesthetic. A small amount of vaginal bleeding is not unusual following hysteroscopy, and the patient should be warned about this. Occasionally, cramping period-like pains are experienced; these should settle within 48 h and respond to paracetamol or a non-steroidal anti-inflammatory drug such as mefenamic acid. Persistent pain and bleeding may suggest a complication such as endometritis, and the patient should seek medical help. The provision of a postprocedure information leaflet is good practice.
Hysteroscopy in outpatients
Provision of hysteroscopy combined with transvaginal ultrasound in outpatients provides a very efficient method of assessing women with pre- and postmenopausal bleeding. As mentioned above, many patients who require a hysteroscopy pose significant risk for general anaesthesia, and are best managed under local or no anaesthetic (Valli et al 1998). In addition, there are many advantages to the patient, including shorter time at the hospital and more rapid return to normal activity. There are also cost advantages to the hospital, as an outpatient clinic is clearly a less expensive environment than an operating theatre (Marsh et al 2004).
Choice of equipment
Choice of equipment will vary with the prior experience of the operator and the facilities available for disinfection/sterilization of the instruments. Rod lens hysteroscopes may be autoclaved, necessitating the provision of an adequate number of scopes for a session of activity. Fibreoptic hysteroscopes, whether rigid or flexible, cannot be autoclaved and must be sterilized with ethylene oxide or closed liquid disinfection systems.
In reality, there are disadvantages and advantages of every system. Rigid autoclavable scopes tend to be of larger diameter, necessitating cervical dilatation in a proportion of cases. The advantage is clarity of view and a fore/oblique view allowing easier examination of the cornua. Flexible scopes are delicate and more expensive, but allow steering through the cervical canal and angulation to allow full inspection of the uterine cavity without any anaesthesia (Kremer et al 1998) (Figure 2.6A). Fibreoptic rigid scopes can be of very small diameter (1.2 mm in a 2.5-mm diagnostic sheath (Figure 2.6B). They are 0° so viewing of the cornua is more difficult, but they are relatively easy to pass through stenosed postmenopausal cervices, leading to a very low failure rate. The Versascope system provides a disposable sheath which can be distended by the passage of a 5 French instrument. This means that a change of sheath is not required to convert a diagnostic procedure into an operative procedure.
Hysteroscopy technique
In the outpatient setting, the authors favour a Cusco’s speculum to bring the cervix into view prior to introduction of the hysteroscope. This allows manipulation of the position of the cervix with the speculum as the scope is inserted to straighten the cervical canal. Rarely, it is necessary to grasp the cervix with a single-toothed tenaculum. Others use no speculum at all when performing vaginoscopy, and locate the cervix before inserting the hysteroscope into it. With the patient awake and the gynaecologist concentrating on passing the scope through a difficult cervix, the role of the attending nurse is paramount (Prather and Wolfe 1995
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