This document outlines a thesis submitted for an MD degree in oncosurgery. The thesis aims to compare the diagnostic accuracy of Pipelle endometrial sampling to dilatation and curettage (D&C) in patients with abnormal uterine bleeding. It also aims to assess if hysteroscopy guidance improves biopsy sampling. The study will involve 200 patients divided into two groups - one undergoing hysteroscopy before biopsy and the other direct biopsy. Both groups will undergo Pipelle sampling and D&C, with samples sent for histopathology analysis. The results will compare diagnostic sensitivity and sample adequacy between groups.

1. By Ahmed Elghandor

2.  Thesis
 Submitted for the Fulfillment of MD Degree in
Oncosurgery

3.  Supervised By
 Prof .Dr. Hamdy Elmarakby
 Professor of oncosurgery,
 National cancer institute, Cairo, Egypt
 Dr. Mohamed Ayaty
 Lecturer of oncosurgery
 National cancer institute, Cairo, Egypt

4. 1. Introduction
2. Aim of the study
3. Patient and methods

5.  Abnormal uterine bleeding is a major gynecological problem,
accounting for 33% of outpatient referrals, including 69% of referrals
in the peri-menopausal and postmenopausal age groups
Siegel et al., 2018

6.  Evaluation of the abnormal uterine bleeding
in women ≥40 years or menopausal women
is of critical importance to confirm the benign
nature of the problem and to exclude
endometrial carcinoma, so that medical or
conservative treatment can be offered and
unnecessary radical surgery can be avoided

7.  Dilatation & curettage (D&C) is the gold
standard for endometrial sampling, but in
60% of cases, less than half of the uterine
cavity is curetted, with the added risk of
general anesthesia, infection and perforation.

8.  This has led to the advent of new and simple
methods for endometrial sampling.

10.  pipelle biopsy device, Vabra and Z sampler
have superseded this technique with good
patient acceptability. Pipelle is a flexible
polypropylene device which works using a
suction mechanism. It can be inserted into
the cervical canal without dilatation making it
an ideal outpatient endometrial biopsy
procedure.

13.  There are very few studies that have analyzed
the efficacy of pipelle biopsy or validated this
method of endometrial sampling against the
gold standard histopathological diagnosis
from hysterectomy specimens. The Pipelle
can be used on an outpatient basis and is
cost effective compared with D&C. However,
there are still concerns regarding the
adequacy of the sample obtained, non-
sampling of focal intrauterine lesions

14.  Office hysteroscopy is frequently
underutilized and is perceived as an invasive
and painful procedure. Many physicians
believe that the specimens obtained with
small 5Fr size instruments preclude an
accurate histological diagnosis.

16.  1-compare the diagnostic accuracy of Pipelle
endometrial sampling and conventional
dilatation & curettage in patients with
abnormal uterine bleeding.
 2- To assess the value of hysteroscopy
guidance in biopsy taking either by pipelle or
D&C


17.  200 females presented with abnormal uterine
bleeding to National cancer institute ,Cairo, Egypt
will be included in this comparative study.
 Detailed clinical assessment of the patients will
be followed by transvaginal sonography and
laboratory investigations (CBC, coagulation
profile, and liver function tests)will be done .
informed consent and approval of the study
protocol by the institute ethics committee will be
issued.

18.  Inclusion criteria
 -Age 40 years or more.
 Endometrial thickness 4 mm or more.
 normal liver function tests
 normal activated partial thromboplastin time
(APTT) and normal platelet count

19.  Exclusion criteria
 Patients with local lower genital causes
 Endometrial thickness <4 mm .
 3-abnormal liver functions tests.
 4-abnormal coagulation profile.
 5-history of pulmonary hypertension or heart
failure.

20.  The patients will be divided into two groups:
hysteroscopy group (group A)and
conventional (non -hysteroscopy )group
(group B). Group A will perform hysteroscopy
first before biopsy while in group B we will
perform biopsy directly.

21.  The Pipelle (Endocurrette, Midvale, Utah, USA)
will be introduced without performing cervical
dilatation and withdrawn outside the uterus
with a rotatory movement to get the sample
which was labeled as sample 1. The cervix
will be dilated and curetted the obtained
sample after D&C will be labeled as sample 2.

22.  Both samples will be sent to a pathologist,
who will be blinded to the methods of
sampling and patients’ medical history for
histopathology assessment. both groups will
compared with each other regarding
sensitivity and adequacy of the collected
sample.

23.  The histopathology reports of the Pipelle
sample will be compared with that of the D&C
sample and the D&C report will be considered
as the gold standard.

24.  Thank you