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Hysteroscopy 0 Hysteroscopy 0 Presentation Transcript

  • Office Hysteroscopy part II procedures MPH Vleugels Riverland hospital Tiel
  • Hysteroscopic procedures in the office
    • diagnostic procedures
    • minor surgical procedures
        • conventional instruments
        • Versapoint ®
    • Essure ® sterilisation
  • Hysteroscopic procedures in the office
        • Versapoint ®
  • “ how long does the procedure take…???? Hysteroscopic procedures in the office
  • Versapoint: CLINICAL RESULTS ANAESTHESIA totaL general local none polyps 95 24 41 30 fibroids 51 14 23 14 septa 8 8 -- -- synechia 7 6 -- 1 others 2 -- 1 1 total 163 51 65 46 M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
  • Versapoint: fibroid size / operation time M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
  • Type intramural extension 0 none I <50% II >50% Submuceus Myoma: Classification
  • Versapoint:fibroids comparison general/local anaesthesia none/local general number: 37 14 type 0 19 (51%) 5 (36%) type I 16 (43%) 7 (50%) type II 2 (6%) 2 (14%) M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
  • Versapoint: polyp size / operation time M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
  • Versapoint: Conclusions for the office
    • small
    • bipolar electrode: coagulation
    • cutting vaporisation
    • active in normal saline
    • fits in 5mm scope
    • learningcurve 3-5 procedures for diagn. scopist
    • safe as long as the principles of hysteroscopy are respected
    Vleugels MPH gyn endoscopy 2002
  • Versapoint: results knowing the specific characteristics = small electrodes, ACCEPTABLE OPERATION TIME 30-45 MIN ???? FIBROID <2CM POLYP <2CM HOW MUCH OF THE PATHOLOGY CAN BE OPERATED WITH THIS ELECTRODE ON THE OFFICE? Hysteroscopic procedures in the office
  • Retrospective analysis 2yrs surgery; 92% of all FIBROIDS TYPE 0 OR TYPE I 47% of all FIBROIDS TYPE 0 84% of all FIBROIDS SMALLER THAN 3 CM 95% of all POLYPS SMALLER THAN 4 CM 70 - 80% can be operated in the office Hysteroscopic procedures in the office How much pathology can be operated in the office?
  • operation settings on OPD
    • continous flow hysteroscope 4.2or 4.9 mm
    • control in/outflow = resorption normal saline
    • cutting (polyps) = Versapoint twizzle electrode
    • vaporizing (fibroid) = Versapoint spring electrode
    • start always presettings VC 1 with small electrodes
    • and decrease to VC2 or VC 3 when touching the wall
    • most important setting = well communicating nurse
  • Versapoint on the OPD Trics for removal polyps
    • Use twizzle
    • cut into pieces
    • present to pathologist!!
    • Do not vaporize
  • Versapoint on the OPD &quot;painting like an artist&quot; Trics for removal fibroid
    • PREMEDICATION:
    • diclofenac supp 2-3 x 100 mg
    • paracetamol 1 x 1000 mg
    • (diazepam 1 x 10 mg)
    • IF NECESSARY:
    • paracervical block lidocain 0.5% + epinephrine 1/200.000
    • MANDATORY IS A GOOD SOCIAL INTELLIGENT NURSE
    • and doctor!!!
    Versapoint: Analgesia on OPD
  • Office Based Hysteroscopic Surgery with a Bipolar Electrosurgery System in Normal saline VERSAPOINT
  • Take home messages………...
    • Surgery L.A./non anaesthesia:
    • informed consent/good communication
    • criterium of speculum examination ( cutner,erian gyn.endo 1996)
    • POLYPS < 3 CM
    • FIBROIDS < 2 CM type 0 and I
    • SYNECHIAE CLASSICATION WAMSTEKER < III
    patient selection for bipolar hysteroscopic surgery in the office Hysteroscopic procedures in the office
    • Surgery general anaesthesia/spinal:
    • patients after cervical surgery
    • POLYPS > 3 CM
    • FIBROIDS  2 CM type 0 and I
    • FIBROIDS type II
    • SYNECHIAE CLASSICATION WAMSTEKER  III
    • SEPTUM
    patient selection for bipolar hysteroscopic surgery not in the office Hysteroscopic procedures in the office
  • Hysteroscopic procedures in the office
    • Essure ® sterilisation
  • Hysteroscopic procedures in the office
    • A new method of female hysteroscopic sterilisation
    • Marketed and sold by Conceptus, Inc.
    • Approved by FDA on Nov. 4 th , 2002
    Essure ® sterilisation
  • Hysteroscopic procedures in the office Essure procedure= Bettocchi vaginal approach
  • Hysteroscopic procedures in the office
  • Hysteroscopic procedures in the office Ideal Placement Spanning the Uterotubal Junction (UTJ) With Deployed Micro-insert Visible in the Uterine Cavity UTJ 3-8 expanded outer coils visible in uterine cavity Hysteroscopic Image 2 4 3 1 4 expanded outer coils Last coil not expanded Uterus Cervix
  • The dutch appraoch
  • Hysteroscopic procedures in the office Can this procedure done on the OPD without any anaesthesia? which method? * procedure time? * pain experience? * placement failure rate * patient satisfaction? ** control after 3 months? *** * Study A n=173; ** study B n=273 *** study C n=160; all studies submitted
  • Flowchart essure sterilisation Intake informed consent gyn examin ultrasound data recording Planning < CD 10 Premedication procedure OPDepartm. Data recording pain score list Ultrasound TVS HSG 1-2-5 followup T=0 T=12wks T=12 wks Hysteroscopic procedures in the office
  • Dutch protocol
    • Planning procedure < 10 e cycle day
        • In case of spontaneous cycle or OAC; no difference!!
        • No need to remove the IUD unless a difficult procedure
    • Premedication
        • Diclofenac 100mg sup at their wake up
        • Diclofenac 100mg sup+1000mg paracetamol orally leaving home
    • Good breakfast/lunch!! Partner present
    Hysteroscopic procedures in the office
  • Essure on the OPD; method without anaesthesia
    • “ Bettocchi”approach=no speculum, no tenaculum, no local anaesthesia, no sedation
    • Dilatation warm Normal saline 0.9%, low pressure, minimal slow movements
    * Study A n=173 accepted Hysteroscopic procedures in the office
  • Evaluation of pain (Visual Analoque Score; 0-10 ): average 2,5 ±2,5 (0-8) median 2,0 two patients got local anaesthesia ; 2/900 Average amongst nulli; 5.2! Dutch experience; Results 2 first clinics Hysteroscopic procedures in the office
  • Hysteroscopic procedures in the office Dutch experience; First 273 patients procedure time introduction of scope till removal
  • Averaged Procedure time related to parity; Multiparae; 10.3 minutes Nulliparae; 15.3 minutes Procedure time related to placement failure rate; Succes placement; 9.8 minutes Failure placement; 24!! minutes Hysteroscopic procedures in the office procedure time Multicenter data netherlands n=1021 21 clinics in 2005
  • Crude failure rate; 7.4% True failure rate=after exclusion Asherman 5.3% Failure rate related to parity (trainings clinic n=297 2002-2004) failure rate nulliparae 32% failure rate multiparae 5.1% Failure rate Multicenter data netherlands n=1021 21 clinics in 2005 Hysteroscopic procedures in the office
  • How do we control the effect? X ray to see whether the device is in abdomen? In the uterus? HSG to prove occlusion of the tubes?? Hysteroscopic procedures in the office
  • Hysteroscopic procedures in the office Control after 3 months by transvaginal ultrasound!!!
  • No X-Ray No- HSG HSG HSG X- Ray A B c Predictive value of US?? Hysteroscopic procedures in the office
  • Hysteroscopic procedures in the office Diagnostic value of Transvaginal Ultrasound Sensitivity: 50% Specifity: 94.6% Pos. predictive value: 99.3 (95% CI: 98.0% - 100.6%) Neg. predictive value: 11% (95% CI:6.0% - 16.0%) Veersema S, Vleugels MPH: fert ster. Dec 2005
  • Hysteroscopic procedures in the office
    • X HSG only required:
    • in unsatisfactory placements
    • after difficult procedures
    • Pelvic X-ray only required:
    • missing device by ultrasound
    13 th Annual Congress of the ESGE, Cagliari, Sardinia In all other cases an ultrasound is sufficient
  • The dutch experience Patients leave straight after Treatment for work or other activities
  • Hysteroscopic procedures in the office
    • It takes twelve weeks for the tubes to be completely occluded.
    • Patient must stay on alternative contraception for the twelve weeks
    After the Procedure
    • Conditions
    • good (diagnostic ) hysteroscopist
    • operating without local anaesthesia;
            • BETTER OUTCOME THAN LOCAL/GENERAL; Ubeda, Lopez, Dhanaut studies
    • create appropiate conditions
            • i.e. social intelligent doctor,nurse
            • i.e. nice surrounding, quiet, music!
            • i.e. work quickly,fluently
            • i.e. good breakfast
            • i.e. extra monitor for patient
    Hysteroscopic procedures in the office
    • take home message
    • Essure has been developed to be used without anaesthesia /without IV sedation in out pat clinic/center,….
    • Using the correct instruments on the proper way after training of the whole team = doctor and assistent,….
    • Respecting the limits of the patient=she is guiding you, then..
    • Control can be done by ultrasound unless a correct protocol has been followed
    • Efficacy, safety and satisfaction of patient and the team will be high
    Hysteroscopic procedures in the office
  • Placement failures: 14 (8%) partial Syndrome of Asherman 5 tubal spasme 2 failure of Essure device ( former type) 1 unknown 4 pre-existant obstruction tubes 2 all 14 patients got laparoscopic sterilisation The dutch experience
    • Thank you, for your attention
    • In case you need more information…
    • Training for Essure protocol….
        • [email_address]
  • Hysteroscopic procedures in the office
  •