Hysteroscopy newsletter vol 3 issue 1 english

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INSIDE THIS ISSUEI
Welcome 1
Histeroscopy Pictures 2
Cervical Stump
Interview of the month 3
Alka Kumar
Brief Review 6
Endometrial cancer
Conundrums 11
Postmenopausal bleeding
Original Article 14
Progress in Hysteroscopy
Global Congress on 16
Hysteroscopy
Hysteroscopy Devices 18
RESECTR
Debate 20
Uniform report system
Ichnandy Arief Rachman
Jan-Feb 2017 | vol. 3 | issue 1
ndonesia is a big country, it’s the fourth populated country in the world and is number
fifteenth of the largest country in the world. We have roughly 70 Millions Female in
reproductive age, but less than 20 percent of our Gynecologist are competence in
Hysteroscopy and laparoscopy. So many colleagues of mine still doing blind D & C.
Our introduction with endoscopy start in the late 80’s when Prof Ichramsjah is coming
back from England (with Jeffcoate) and bring one Wisap full laparoscopic hysteroscopic
tower and instrument. And in early 90’s, Prof Jacob have opportunity to study in German
(with Kurt Semm) and also to Brussels (with Jacques Donnez). After his return to
Indonesia many Indonesian OG learn this technique for the first time from them. Since
then many Indonesian gyne went to Leuven (with Jacques Donnez) and some to Nashville
(with James Daniell) in the late 90’s.
It was not until the year 2000 when IGES (Indonesian Gynecology Endoscopy Society)
formed in Bali with the inniative from Prof Wachyu, Prof Duddy, Prof Hadibroto, dr Nadir
Chan (sponsored by Anastasia `Ussia and Koninckx Phillipe). But still gynecology
endoscopy is not in the Indonesian Obstrician Gynecologist program Curiculum until
2009. With so many Island to cover it’s quite difficult to introduce gynecology endoscopy
through out the nation. IGES first training center in the university hospital was conducted
by Prof Wachyu at first National Hospital, Raden Saleh Building – University of Indonesia.
Back then it’s more into hysteroscopy diagnostic and laparoscopy operative, the
development of operative hysteroscopy expand more in the private sector but not in the
university teaching hospital.
Second generation gyne endoscopist, emerged after the first IGES National Congress in
Jakarta in 2009. Have met famous names like Hugo Verhoeven, Hans Tinneberg etc
encourage most of us seeking scholarship abroad. With Scholarship from the Dutch
School of Gynecologie en pelvic surgery I was with Marlies Bongers and Andreas
Thurkow in Holland, while my other colleague Anggie with Sebastiaan Veersema, Herbert
went to Clermont Ferranc, Lucky went to KK Hospital and Ferdhi practically graduated
from Germany. Together all of us together with Prof Wachyu, Prof Jacoeb, dr Nadir etc
started to give basic office hysteroscopy and operative workshop on National Obstrician
Gynecology Meeting or IGES Congress.
Many of the new technique are do able, but regarding expense and cost it is still problem
to spread the technique during OG registar program. Among 12 `IGES training center we
have today, only 2 center at the teaching hospital who has complete facility for Office and
Operative Hysteroscopy (outpatient and theatre patient setting). One is at the private
patient sector on first National Hospital and the other one is at my center at the public
patient sector on The presidential Hospital – Indonesia Army Central Hospital Gatot
Soebroto.
As the Course Director for IGES Training Center at The
presidential Hospital – Indonesia Army Central Hospital and on
behalf of the IGES I look forward for the event in Barcelona this
May 2017. Many of us want to come there to learn and to share
our experience. See you in Barcelona !!

TEAM COODINATOR
SPAIN
L. Alonso
EDITORIAL COMMITTEE
SPAIN
E. Cayuela
L. Nieto
ITALY
G. Gubbini
A. S. Laganà
USA
J. Carugno
L. Bradley
MEXICO
J. Alanis-Fuentes
PORTUGAL
J. Metello
ARGENTINA
A. M. Gonzalez
VENEZUELA
J. Jimenez
SCIENTIFIC
COMMITTEE
A. Tinelli (Ita)
O. Shawki (Egy)
A. Úbeda (Spa)
A. Arias (Ven)
M. Rodrigo (Spa)
A. Di Spiezio Sardo (Ita)
E. de la Blanca (Spa)
A. Favilli (Ita)
M. Bigozzi (Arg)
S. Haimovich (Spa)
R. Lasmar (Bra)
A. Garcia (USA)
N. Malhotra (Ind)
J. Dotto (Arg)
I. Alkatout (Ger)
R. Manchanda (Ind)
M. Medvediev (Ukr)
M. Elessawy (Ger)
All rights reserved.
The responsibility of the signed
contributions is primarily of the authors
and does not necessarily reflect the views
of the editorial or scientific committees.
HYSTEROSCOPY
PICTURES
2
The debate about whether supracervical hysterectomy, when performed for benign
conditions, has benefits over a total hysterectomy, remains open. There are many
arguments both for and against performing a supracervical hysterectomy.
Among the different arguments presented, it is clearly demonstrated by different
studies that a supracervical hysterectomy involves shorter surgical time, associated
lower blood loss and faster postoperative recovery. It has also been argued that
preservation of the cervical stump has positive implications in the sexual response as
well as favors the support of the pelvic floor and urinary function, although the latter is
yet to be confirmed.
It is clear that the main difference between one technique and the other lies in the
preservation of the cervical stump and in possible problems associated with it. These
include the development of cervical cancer in the remaining cervix that is estimated to
occur in less than 1% of patients. The other associated problem is persistent cyclic
menstrual bleeding after surgery, this happens between 0% and 25% of cases
according to the different series.
If you are interested in sharing your cases or have a hysteroscopy image that
you consider unique and want to share, send it to hysteronews@gmail.com
Superficial vaginal
endometriotic implant
Fibrous tissue / whitish
fibrous scar tissue
Detail of the cervical stump

3
INTERVIEW WITH...
Consultant hysteroscopic surgeon and inventor. Two different
facets of her passion about hysteroscopy. Her main interest is in
the field of 'Fluid management Systems' for endoscopic surgery.
Alka Kumar
Director Women's Health
Centre, Vaishali Nagar
Consultant Hysteroscopic
Surgeon at Anil Nursing Home
Jaipur, India
How has hysteroscopy developed in India in the last years ?
In the last 20 years, hysteroscopy has grown much in India and
developed its own place. It seems now it is in a groove and has a niche
for itself. We are having dedicated hysteroscopy workshops, conferences
and congresses. Alongside there are a lot of young gynecologists who
have developed a great interest in the subject.
We have had new developments from our country in hysteroscopy as
fluid management systems and newer morcellators. There are many
publications in hysteroscopy from India amongst which we are on the
cover pages of reputed journals like Fertility & Sterility, JMIG and IJOG.
You’re an expert in hysteroscopy and TBC. Whats your reflection
about genital TBC?
Unlike the western countries endometrial TB is rampant in India with
newer cases emerging each day. It is one of the leading causes of
primary infertility, secondary infertility and asherman. Endometrial TB is
usually a continuation of abdominal TB with the tubes and ostia involved
in many cases. Genital TB often presents itself with no clinical features
other than infertility. The common sites of GTB are fallopian tubes 90-
100%, endometrium upto 50%, ovaries 10-30%, cervix vagina and vulva
are fairly uncommon. Hysteroscopy is a powerful tool in raising a strong
suspicion, and in diagnosing endometrial TB by evaluating endometrial
architecture and the appearances of the tubal ostia and finally confirming
the diagnosis by tests like DNA PCR and BACTEC for Acid Fast Bacili. A
detailed history especially related to TB is a must before taking up the
case for hysteroscopy. Disease pathology like adhesions need to be
corrected at the time of hysteroscopy. Severe cases of asherman
syndrome do not have a good prognosis in terms of achieving a
pregnancy even with ART procedures.
Once ATT is started it is very helpful to do a relook hysteroscopy after 6
months to see the efficacy of the chemotherapy and to evaluate the
endometrium regeneration.
”The common sites sites of GTB are fallopian tubes 90-100%,
endometrium upto 50%, ovaries 10-30%, cervix vagina
and vulva are fairly uncommon”
Flimsy adhesions with
attached granuloma
Bizarre endometrium

4
Which are the hysteroscopic patterns of this disease ?
According to our data from 1992 to 2016 , we have encountered some specific hysteroscopic markers which
are common to cases of endometrial TB:
I) Bizzare endometrial character: where the endometrium loses its color, glands and starts to look dirty,
pale, white powdery nibbled, and has flimsy adhesions.
II) Granulomas or tubercles: They appear as small pale white irregular objects either on the endometrium
directly or attached to flimsy adhesion bands. The tubercles vary in size.
III) Adhesions: From flimsy adhesions to moderate to severe adhesion bands, and often when looked closely
these adhesions have tubercles /granulomas that look like whitish colored irregular deposits that are attached
on the adhesions. It is very important therefore to start doing hysteroscopy at very low flow rates so that the
deposits do not get washed away with continuous fluid irrigation.
IV) Tubal ostia: Tubal ostia are commonly involved in endometrial TB. The minor endosalpigean folds are
scarred, white, pale and usually devoid of the longitudionally arranged vascularity. The ostia usually do not
show the normal opening and closing physiological motion at lower intrauterine pressures. Flimsy large
adhesion bands may be seen surrounding the ostia. Sometimes the ostia are completely hidden behind
adhesions. Flimsy adhesions can also be seen in the intramural part of the ostia.
We know that you have a new hysteroscopy pump to monitor the real time rate of fluid intravasation.
Can you tell us some words about it and what’s your opinion about intrauterine pressure during
hysteroscopy ?
Our pump is based on a dual peristaltic pump patented technology. The pump continuously displays the real
time rate of fluid intravasation into the systemic circulation of the patient and it also displays the total fluid
deficit without any weight measurement. It is important to understand the differences between real time rate
of fluid intravasation and the total fluid as depicted in the table below:
” Intrauterine pressure during hysteroscopy is one of the
most important parameter in hysteroscopic surgery”

5
The pump gives a predictably constant visualization and desired mechanical distention at all points of time
during the surgery. The pump constantly displays the true intra uterine pressure at all points in surgery. Any
desired intrauterine pressure can be maintained for any desired uterine cavity flow rate since, pressure and
flow rate, are absolutely independent of each other. The pump helps in significantly reducing the learning
curve and increases the surgeon’s confidence.
Intrauterine pressure during hysteroscopy is one of the most important parameter in hysteroscopic surgery
because this parameter directly influences visualization, mechanical distension and fluid intravasation.
Intrauterine pressure has great significance in office hysteroscopy as it is directly related to the pain threshold
of the patient. Higher pressure may promote excess intravasation while lower pressure impairs visualization
and mechanical distension. Ideal intrauterine pressure will result in proper stable distension and visualization.
There will be predictable separation of the intrauterine walls, therefore resulting in lesser fluid absorptions.
How can we help to the promotion of the hysteroscopy ?
The youngsters should be encouraged to visit the OR and to assist the experienced surgeons. hands on
training with simulators should be undertaken as much as possible. Live operative workshops and
hysteroscopy conferences should be attended with full concentration by the learners.
The experienced surgeons must preserve a data bank of their videos and still images. Unedited videos are
perhaps more useful than their edited versions. Such videos and images shall help the learners in enhancing
their skills, shortening the learning curve, and in understanding the complications and their management in a
better manner. Data from surgeries must be meticulously preserved and tabulated so that more and more
publications are accomplished. Unusual images, cases and any complication should be reported for the benefit
of all.
Do you have any advise for the young physician who is starting out in the world of surgery ?
For starting in hysteroscopy it is very important that the young surgeon pays as much attention to the physics
of the instruments and devices he will be using for both hysteroscopy in the office and the OR set up.
Hysteroscopy involves a lot of instrumentation and energy sources. Understanding these will not only make
hysteroscopy easier but also safer.
The uterus is a collapsed cavity and requires distension for separation of the walls. It is this distension that
allows proper visualization. Therefore the significance of proper distension and intrauterine pressure has to be
understood. It is advisable to use a good fluid management system.
Take baby steps – start with simple diagnostic office hysteroscopy and then go on to moderate and difficult
procedures. There is a specific place of resectoscopy in hysteroscopy and that should be kept in mind while
learning the procedure. Always keep the fluid intravasation and balance in your mind, even while doing
simple procedures and above all, be mindful in the operating seat.
” Take baby steps – start with simple diagnostic office hysteroscopy
and then go on to moderate and difficult procedures.”

6
Endometrial cancer is the most common gynecological cancer in developed countries and is the 5th most
frequent cancer affecting woman. The estimated frequency is 19.1 / 100,000 cases in the USA and Canada
and 15.6 / 100,000 in Europe.
It is usually associated with menopause, although up to 14% of cases are diagnosed in premenopausal
women and up to 5% of cases in patients under the age of 40 years. It is usually diagnosed in early stages and
with the tumor usually confined to the uterine cavity, which generally gives it a good prognosis
The main risk factor is continued unopposed exposure to elevated estrogen levels. Among the different
causes related to endometrial cancer are:
1- Obesity: is present in 40-50% of endometrial carcinomas in developed countries. Obese women are 2-4
times more likely to develop endometrial cancer than non-obese women.
2- Unopposed estrogen therapy (UET). The use of UET greatly increases the formation of endometrial
hyperplasia and endometrial carcinoma. This risk increases in relation to the dose and duration of the
exposure. The administration of progesterone during HRT eliminates the risk of both endometrial hyperplasia
and carcinoma.
3- Tamoxifen: It is a selective estrogen receptor modulator (SERM) that is commonly used as an adjuvant
hormone treatment in women with breast cancer. The use of tamoxifen is associated with a 2-5-fold increased
risk of developing endometrial pathology, including polyps and endometrial cancer.
4- Hereditary: Endometrial carcinoma may appear in the context of a Lynch II syndrome or hereditary
colorectal cancer not associated with polyposis (HNPCC). It is an autonomic dominant disorder with
incomplete penetrance. Women with HNPCC have a risk of about 50% developing endometrial cancer.
Since the work of Bokhman, endometrial cancer has been divided histologically into two types, type I and
type II.
Brief Review
Endometrial Cancer

7
Type I: It represents 80% of the total of cases of endometrial cancer and corresponds to endometrioid
adenocarcinoma, so named because it histologically mimics the normal endometrium. There are several
subtypes such as villoglandular, secretory and ciliated cells.
Type II: Represents 20% of the total of cases of endometrial canecr. There are different histological
subtypes, being the papillary serous the most aggressive with invasion both to the myometrium and intra-
vascular space with consequent poor prognosis. The remaining histological subtypes such as clear cell,
mucinous, among other are less frequent.
The main symptom of presentation is abnormal uterine bleeding in 90% of cases. Endometrial
carcinoma should be suspected in patients with postmenopausal vaginal bleeding, postmenopausal
pyometra, and perimenopausal patients with increased intermenstrual bleeding.
Diagnostic hysteroscopy with targeted biopsy is currently the ideal method for the diagnosis of
endometrial cancer, reaching a sensitivity of almost 100%.
Osamu Sugimoto (Sugimoto, O. (1975). Hysteroscopic diagnosis of endometrial carcinoma A report of
fifty-three cases examined at the Women's Clinic of Kyoto University Hospital, American Journal of
Obstetrics and Gynecology, 121 (1), 105- 113) highlighted the role of hysteroscopy in the diagnosis of
endometrial carcinoma as well as in the assessment of extension and cervical involvement.
Sugimoto defined four hysteroscopic patterns of endometrial adenocarcinoma
1-Polypoid: With polypoid and histologically well
differentiated growth. The surface has few atypical
blood vessels and is usually whitish-grayish.
2-Nodular: Solid appearance with very marked
atypical vascularization and the existence of atypical
vessels in zigzag on the surface of the tumor.
3-Papillomatosis: is the most commonly pattern
present in more than 50% of patients with endometrial
carcinoma. Although of a nodular appearance, the
detailed examination reveals a surface covered with
numerous tentacle-like projections. Each projection is
composed of a blood vessel covered with cancerous
tissue.
4-Diffuse Carcinoma: When the entire endometrial
cavity is affected. Usually, this pattern is associated
with poorly differentiated carcinoma. Cases of
metastatic carcinoma usually present this pattern.
Another important factor to consider in the hysteroscopic assessment of endometrial carcinoma is the
determination of the existence of cervical involvement. The hysteroscopy allows to easily identify the
internal cervical os, which offers a great precision in the assessment of the extension towards the cervical
canal.

8
Dr. Francisco Coloma established another hysteroscopic morphological classification of endometrial
cancer (Coloma, F., Costa, S., Bartret, FB, Diago, VJ, Payá, V., Rodenas, JJ & Aguilar, JG (2006).
Morphological-hysteroscopic examination of endometrial cancer. Progress of Obstetrics and Gynecology,
49 (10), 553-559.) Based on the observation of 272 cases of patients with endometrial cancer. The
authors defined three patterns (pseudohyperplastic, nodular and malignant polyp) and an advanced sub-
pattern that can affect any of the three patterns.
1-Pseudohyperplastic: image similar to a "seaweed pattern", with individual papillae and vascularization
in each one of them. It is subdivided into focal, which appear as a plaque and diffuse, in which there is
extension of more than 50% of the endometrial surface.
2-Nodular: appears as compact nodules, attached to the endometrial wall. These nodules have aberrant
characteristic and atypical vascularization.
3-Malignant transformation of a polyp: endometrial polyps with signs of malignancy either total or
partial.
The three patterns represent an advanced sub-pattern with fibrin deposits and necrotic areas. In
addition, they frequently present with mucometra or pyometra.
It is interesting to note that in this study a comparison was made between the different hysteroscopic
patterns and the surgical stage of the disease. It was observed that the pseudohyperplastic pattern
without advanced signs is usually associated with earlier surgical stages, as is the case with the
malignant polypoid pattern. The nodular pattern without advanced features is usually associated with
intermediate stages Ib 54% and, finally, in the presence of an advanced sub-pattern, the surgical stage is
Ic or higher in 66% of cases, regardless of the initial pattern.
This same study correlated the hysteroscopic pattern with the
histological grade, noting that the pseudohyperplastic pattern is
usually associated with a well differentiated histological grade,
whereas a nodular pattern is usually associated with poorly
differentiated patterns.
Recently, Dr. Su Hsuan has published his observations on a
pattern called the "glomerular pattern" (Su, H., Pandey, D., Liu,
YY, CF, Wang, CJ, Huang, KG, & Lee, CL 2016) Pattern
Recognition to Prognosticate Endometrial Cancer: The Science
Behind the Art of Hysteroscopy-A Retrospective Study.
International Journal of Gynecological Cancer, 26 (4), 705-710).
The data presented in this study correlate this pattern with
tumors of high histological grade and with advanced disease.
It is necessary to unify these and other published
classifications to obtain a common classification, which will
serve as a basis for hysteroscopists and to correlate the
hysteroscopic image with the surgical and histological grade. It
is also necessary to establish a correct protocol for the
evaluation of endometrial cancer by hysteroscopy, taking into
account the images, directed biopsy and evaluation of the
possible involvement of the cervical canal.
Nodular pattern
Hysteroscopy Newsletter
Pseudohyperplastic pattern

9
Gel barriers have been proven to have a significant clinical effect
on IUA prevention (Level of evidence 1b)
The resectoscope was originally introduced into gynecologic
practice by Robert Neuwirth in 1978 for the excision of submucous
fibroids.
DID YOU KNOW...?

10
Answer to the previous issue:
Osseous metaplasia
Mastering the
Techniques in
Hysteroscopy
O. Shawki, S. Deshmukh
L. Alonso
Jaypee
Year 2017 774 pages
Includes Interactive DVD-ROM
This textbook is designed in such a
way that it gives complete knowledge
about the uterus, i.e. anatomy,
physiology, instruments and gadgets
and its applications along with the
current and recent advances in
hysteroscopy. There are many
sections in this book dedicated to
each problem, and various opinions
and methods to solve it by stalwarts in
hysteroscopy. It also includes the tips
and tricks to master hysteroscopy.
This book is blessed with many gifted
international as well as national
figures of India, who are specialized
in hysteroscopic surgeries.
Sometimes, when performing hysteroscopy, it is
important to pay attention to every corner of the
uterus, as Vasari stated «cerca trova», «he who
seeks finds»
WHAT'S YOUR
DIAGNOSIS?

11
Lookforus:hysteroscopygroupinLinkedIn
A recently published meta-analysis "The accuracy of endometrial sampling in women with postmenopausal
bleeding: a systematic review and meta-analysis" concludes that "In women with postmenopausal
bleeding, the sensitivity of endometrial sampling to detect endometrial cancer and especially atypical
hyperplasia and endometrial disease, including endometrial polyps, is lower than previously thought". How
do you manage postmenopausal bleeding? Do you yhink that Hysteroscopy has to be the first option after
the US? Is there still a place for a "Blind" Biopsy?
Hysteroscopy Conundrums
Postmenopausal Uterine Bleeding

12
Lookforus:hysteroscopygroupinLinkedIn

13

14
Hysteroscopy is a rapidly developing field of gynecologic practice, progressing from an inpatient to
an outpatient procedure. Today hysteroscopy is the gold standard for evaluation of the endometrial cavity
with more accuracy than blind methods, and gives the possibility to more accurately diagnose uterine
abnormalities in patients presenting with pre or postmenopausal uterine bleeding, intermenstrual spotting, or
infertility [1].
It took more than a hundred years since the first time hysteroscopy was performed in 1869 by D.C.
Pantaleoni. He used a device similar to a cystoscope. In 60-year-old woman it was found an endometrial
polyp, which probably caused uterine bleeding [2].
Subsequently technological part has been modified significantly with dramatic improvement of
examination conditions (preliminary removal of blood from the uterus, stretching of the walls of the uterus
with distention media). A new era came after the introduction into medical practice portable optics and optics
with rigid lens systems and later introduction of video camera, improvements of lighting possibilities.
The introduction of electrosurgery in hysteroscopy has created a new surgical areas unknown
before. Today a big number of surgical procedures are carried out by means of hysteroscopy avoiding
laparotomy and sometimes hysterectomy [3].
The advent of small-sized instrumentation with a final diameter of <5 mm turn hysteroscopy into a
safe and more comfortable intervention and permit it be performed as an office procedure without
anesthesia. In 1997, Bettocchi et al developed the “vaginoscopic approach” or “no-touch technique” for the
atramautic insertion of the hysteroscope into the external uterine orifice, without the aid of the speculum or
the tenaculum, introducing the scope directly into the vaginal canal. This method reduces patient discomfort
and allows the performance of endoscopic examination even in nulliparous patients or in postmenopausal
women who have severe vaginal atrophy or stenosis [4-8]. In fact, the miniaturization of the instruments
effectively reduces the difficulties both for the operator and for the patient, allowing even less skilled
gynecologists to perform office hysteroscopy. Moreover, it has been demonstrated that a smaller
hysteroscope size makes its introduction easier and less painful compared with conventional ones [3, 9, 10].
One of the small hysteroscopes is a thin 3.2-mm semi-rigid
mini-hysteroscope (Versascope, Ethicon Inc., Somerville, NJ, USA)
with a disposable sheath and 1.9-mm fibre optic (Alphascope).
Another one is CAMPO TROPHYSCOPE 2,9 mm thin with the
Office Continuous Flow Operative Sheath 4.4 mm, Karl Storz.
Innovative feature of the last one are sheaths with gliding
mechanism: primary approach to uterine cavity with 2.9 mm outer
diameter and than intraoperative changeover from single-flow to
continuous-flow and operating sheath. The operative procedure is
facilitated by 7- Fr or 5-Fr mechanical instruments, which is
compatible with a 5-Fr bipolar electrode [11].
Dramatic progress in Hysteroscopy
Mykhailo V. Medvediev, MD, PhD, ScD
Professor, Department of Obstetrics and Gynecology,
Dnepropetrovsk medical academy of Health Ministry of Ukraine
Original Article
Fig.1. Prof. Stefano Bettocchi, Italy

Additionally, to decreasing of scopes caliber there are new mechanical and bipolar instruments been
developed these days. Some data showed high efficacy and tolerability of new instruments for out-patient
operative hysteroscopy. In one study the outpatient polypectomy was associated with a success rate of 95%.
Other outcomes such as discomfort after the procedure, time away from home, analgesia requirements,
description and satisfaction of the procedure were all in favour of the outpatient setting. Further, patients in
the outpatient group recovered faster [12].
Recently even more portable devices of office
hysteroscopy have been introduced to the market. One of these
is EndoSee device (CooperSurgical, Trumbull, CT, USA). The
Endosee Hysteroscope is a lightweight, handheld, battery
operated portable system. It is used with a single-use
Disposable Diagnostic (Dx) Cannula with a camera and light
source at the distal end to illuminate the area for visualization
and image and video capture. The video signal is electronically
transferred to the main body of the hysteroscope via an
electrical connector. An LCD touch screen display monitor on
the hysteroscope is used for viewing [1].
At present, conventional hysteroscopic resection can be considered the gold standard procedure for
major hysteroscopic operations. Despite well-recognized advantages of resection, several problems, such as
fluid overload, uterine perforation due to electric current, lack of visualization and need of removal of
resected fragments resulting in a time-consuming procedure, thermal damage to endometrium with
permanent detrimental effects on future fertility and relatively long learning curve, remain still unsolved.
Invention of mechanical hysteroscopic morcellators has made a great improvement in management
polyps and myomas. Hysteroscopic morcellator was developed to reduce problems mentioned above and
decrease an operative time comparing with traditional approach. Hysteroscopic mechanical morcellation
allows removal of the tissue automatically during hysteroscopic resection and leads to a reduced operating
time. There is evidence that the learning curve for use of the hysteroscopic morcellator is shorter than for
conventional monopolar resectoscope in relative novices [11].
Hysteroscopy has become an important tool to evaluate
intrauterine pathology including endometrial polyp, submucous
myoma, intrauterine adhesions and uterine anomaly. In most
cases, the diagnosis and treatment of these lesions can be
performed in the office or outpatient setting without need for
anesthesia. Smaller, more portable systems are now able to
provide good views and with image storage facilities. As a
consequence, a single room can be used for various purposes,
providing more opportunity for the development of outpatient
facilities for ambulatory gynecology.
1.Connor, M., New technologies and innovations in hysteroscopy. Best Pract Res Clin Obstet Gynaecol, 2015. 29(7): p. 951-65.
2.Siegle, A.M., The early history of hysteroscopy. J Am Assoc Gynecol Laparosc, 1998. 5(4): p. 329-32.
3.Kogan, L., et al., Operative hysteroscopy for treatment of intrauterine pathologies does not interfere with later endometrial development in patients undergoing in vitro fertilization. Arch
Gynecol Obstet, 2016. 293(5): p. 1097-100.
4.Bettocchi, S. and L. Selvaggi, A vaginoscopic approach to reduce the pain of office hysteroscopy. J Am Assoc Gynecol Laparosc, 1997. 4(2): p. 255-8.
5.Cooper, N.A., et al., Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain. BJOG, 2010. 117(5): p. 532-9.
6.Lin, B.L., et al., The Fujinon diagnostic fiber optic hysteroscope. Experience with 1,503 patients. J Reprod Med, 1990. 35(7): p. 685-9.
7.Bettocchi, S., et al., Advanced operative office hysteroscopy without anaesthesia: analysis of 501 cases treated with a 5 Fr. bipolar electrode. Hum Reprod, 2002. 17(9): p. 2435-8.
8.Marciniak, A., et al., [Role of office hysteroscopy in the diagnosis and treatment of uterine pathology]. Pol Merkur Lekarski, 2015. 39(232): p. 251-3.
9.Campo, R., et al., Office mini-hysteroscopy. Hum Reprod Update, 1999. 5(1): p. 73-81.
10.Di Spiezio Sardo, A., et al., Ambulatory management of heavy menstrual bleeding. Womens Health (Lond), 2016. 12(1): p. 35-43.
11.Closon, F. and T. Tulandi, Future research and developments in hysteroscopy. Best Pract Res Clin Obstet Gynaecol, 2015. 29(7): p. 994-1000.
12.Marsh, F.A., L.J. Rogerson, and S.R. Duffy, A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy. BJOG, 2006. 113(8): p. 896-901.
15
Fig. 2. CAMPO
TROPHYSCOPE 2.9 mm
with the Office Continuous
Flow Operative Sheath, Karl
Storz
Fig. 3. EndoSee device (CooperSurgical,
Trumbull, CT, USA)
Fig. 4. Intrauterine BIGATTI Shaver, Karl Storz

16
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17
Some Pictures
Meeting Friends at Nagpur. Focus on Hysteroscopy Congress
Jose "Tony" Carugno, Sushma Deshmukh, osama shawki,
Luis Alonso Pacheco & Sergio Haimovich. All will attend the next
Global Congress on Hysteroscopy. Are you going to miss it?
Stefano Bettocchi, honorary member of the Global
Congress on Hysteroscopy with Franklin Loffer and
Alessandro Buda. APAGE and TAMIG 2016 Taipei
Prof. Jorge Enrique Dotto and Prof. Linda Bradley in the
latest AAGL congress, Orlando (Florida) Exchanging ideas
about the next Global Congress on Hysteroscopy
Dr. Jose Caruno (USA) Dr. Luis Alonso (SPA) , Dr. Sergio
Haimovich (SPA) and Milind Telang (IND).
Relaxing time in Nagpur

18
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HYSTEROSCOPY
RESECTR
High-performance disponsable tissue resector
Basic manual devices are cost-efective ans easy-to-use, but often lack speed, power, control, and effectiveness.
Electromechanical system may improve speed and power for certain cases, but require costly capital equipement,
complex set-up and expensive disponsables. Some electromechanical systems introduce new procedural risks that may
outweigh their benefit.
The RESECTR ia a single –use, non-powered, hand-held, and hand-manipulated system designed to combine the
benefits of basic manual devices and electromechanical powered systems.
Clinicians squeeze and release the handle with their fingers to actuate cutting speed and control. Improved control
means physicians can perform tissue resection based on what they see and feel during the procedure.
RESECTRs are 100% disponsable , ship “ready-to-use”, and do not require new capital equipement, complex set-up, or
service contacts to cut.The cost-effective RESECTR can also be used in a variety of clinical settings allowing
physicians to “see-ans-treat” lesions in the hospital, clinic, surgery centre or office.
A systematic review and meta-analysis of randomized controlled trials comparing hysteroscopic
morcellation with resectoscopy for patients with endometrial lesions
International Journal of Gynecology & Obstetrics, 2016.
Li, C., Dai, Z., Gong, Y., Xie, B., & Wang, B.
Four trials including 392 patients were analyzed. Successful removal of all endometrial lesions was more frequent with
hysteroscopic morcellation than conventional resectoscopy (odds ratio 4.49, 95% confidence interval [CI] 1.94–10.41;
P<0.001). Total operative time was also shorter with hysteroscopic morcellation (mean difference −4.94 minutes, 95% CI
−7.20 to −2.68; P<0.001). No significant differences in complications were found. Meta-analyses were not possible for
tolerability and learning curve. In one study, hysteroscopic morcellation was acceptable to more patients (P=0.009).
Conclusions: Hysteroscopic morcellation is associated with a higher operative success rate and a shorter operative time
among patients with endometrial lesions than is resectoscopy. More high-quality trials are required to validate these results.
http://www.resectr.com

19
HIGHLIGHT ARTICLES
Published on different medias
BACKGROUND: Minimally invasive surgery is a major pillar of gynecological surgery. However, there are
very few training opportunities outside the operation theater (OR) due to the cost and equipment requirements
of organ simulators, virtual reality trainers (VRT) are promising tools to fill this gap.
METHODS: Experienced and inexperienced participants of a minimally invasive surgery course followed
the standardized HystSim™-VRT training program.
RESULTS: Performance of 39 Participants (15 inexperienced and 24 experienced) was evaluated in the
standardized hysteroscopic program HystSim™. Tasks included three rounds of both a polyp and a myoma
resection. Primary measurements were improvement in resection time, cumulative resection path length, and
distention media use.
CONCLUSION: The HystSim™-VRT is an effective tool to improve the psychomotor skills needed in
hysteroscopic surgery for experienced and inexperienced surgeons prior to OR exposure. Additional organ
models training is advisable for hysteroscopic haptic skills.
Evaluation of the HystSim™-virtual reality trainer: an essential additional tool to
train hysteroscopic skills outside the operation theater.
Neis F, Brucker S, Henes M, Taran FA, Hoffmann S, Wallwiener M, Schönfisch B, Ziegler N, Larbig A, De Wilde RL.
Surg Endosc. 2016 Nov;30(11):4954-4961.
BACKGROUND: In Australia, gynaecologists continue to investigate women with abnormal bleeding and
suspected intrauterine pathology with inpatient hysteroscopy despite some evidence in the literature that that
there is no difference in safety and outcome when compared to an outpatient procedure.
AIMS: This prospective study assessed the safety, effectiveness and acceptability of outpatient hysteroscopy
over 11 years at a tertiary hospital in Australia. Resource savings were then calculated.
MATERIALS AND METHODS: A prospective database was analysed from March 2003 to January 2014
(130 months, 990 women).
RESULTS: Successful hysteroscopic access was obtained in 94% of cases. Twenty-six percent of patients
required a second procedure, including 132 for endometrial polyps and 33 for submucosal fibroids that were
not able to be treated in the outpatient setting. On questioning, 88% of women would be happy to have the
procedure again. Factors affecting success were pre-procedure pain, menopausal status and previous vaginal
delivery. The difference between pain experienced versus pain expected was a major factor in patient
acceptability. A vasovagal episode occurred in 5% of cases.
CONCLUSION: Outpatient hysteroscopy was demonstrated to be safe, effective and acceptable to women.
Provision of an outpatient hysteroscopy service saves theatre time and approximately $1000 per case.
Improved techniques and technology will allow progression to a 'see and treat' service, providing further
savings. With budget constraints, increasing wait times for major procedures and concerns about trainee
surgical experience, an outpatient hysteroscopy service should be considered the 'gold standard' investigation
over hysteroscopy in theatre.
Is outpatient hysteroscopy the new gold standard? Results from an 11 year
prospective observational study.
Ma T, Readman E, Hicks L, Porter J, Cameron M, Ellett L, Mcilwaine K, Manwaring J, Maher P.
Aust N Z J Obstet Gynaecol. 2016 Nov 15. [Epub ahead of print]

20
Debate
DIAGNOSTIC HYSTEROSCOPY. Uniform report system
Raquel Duarte
Gynecology Service Hospital Quironsalud Málaga. Spain
Outpatient hysteroscopy is an increasingly widespread diagnostic and therapeutic tool in gynecology. Its use
allows the study of the uterine cavity, with the objective of diagnosing and sometimes even treating
malformations, polyps, fibroids, endometrial alterations, among other conditions.
Every "surgical" procedure must be well documented in the operative report, to make clear the findings and
procedures that have been performed.
Regarding diagnostic hysteroscopy, the report not only describes the procedure, but will be used as
complementary evidence for a future approach to the patient's pathology. A detailed description of all
findings will aid in planning any needed subsequent procedure or to modify aspects of the treatment to be
performed.
In cases in which the gynecologist who
performs the hysteroscopy is not the same
who will perform any subsequent procedure,
a standardized and detailed report will guide
any subsequent provider. In current practice,
each hysteroscopist performs the diagnostic
report according to his/her criteria, leaving
some characteristics without enough detail
that may have an impact on a future
treatment.
In other areas of gynecology in which
diagnosis is based on imaging, as in
colposcopy, strict criteria and specific
nomenclature have been unified for each
type finding (1). Would it be necessary to
propose the same unification of criteria
when performing a hysteroscopic
examination? Will the creation of a standard
report in which all the aspects that can be
assessed during hysteroscopy are clear?
The answer is probably yes. Most hospitals are providing outpatient hysteroscopy services and these
hysteroscopic studies will be evaluated by other colleagues in consultation to establish proper diagnosis and
treatment.
The current technological advances allow us to perform the recording or taking pictures of the procedure,
which facilitates the later information in case it is needed. Even so, it will probably be much more efficient
and easier to manage a report with all the detailed information and using the same structure, facilitating to
find every aspect of the hysteroscopic procedure, including even a graphic outline of the findings.

During hysteroscopy, the following areas can be assessed: The vaginal walls, uterine cervix, cervical canal,
uterine cavity morphology and size, visualization of the tubal ostium, and the endometrium.
There is not much literature on making a standard or unified report of hysteroscopic findings. Only in
Colombia, in 1998, they created a report, similar to the one they use for laparoscopies (2). This article intends
to expose the necessity to create a unified hysteroscopy report and a proposal of the same is presented.
HYSTEROSCOPY REPORT:
Patients Name: Medical Record Number: Date of procedure:
Age:
Hysteroscopist:
Gynecological history:
Last Menstrual Period:
OCP: Yes No
Indication of the procedure:
Infertility
Abnormal uterine bleeding
Suspected Mullerian anomaly
Other:
Procedure lenght (minutes):
Equipment used:
Hysteroscope:
Distension Media: Saline Glycine
Analgesia: Yes No
Vaginoscopy: Normal Abnormal (Findings)
Cervix: Normal Abnormal (Findings)
Cervical canal: Open Stenotic: Yes No This report should have a
schematic drawing of the findings
Morfology and size of the uterine cavity:
Normal
Abnormal: septum tubular arcuate other (describe)
Endometrium: Atrophic Polypoid Irregular Proliferative Scratch Other
Visualization of bilateral tubal ostium:: Yes No (why):
Intrauterine Patology: No Yes (describe)
Endometrial biopsy: Yes No
Clinical Impression:
Complications: No Yes (describe)
21
www.hysteroscopy.infoJan-Feb 2017 | vol. 3 | issue 1

22
As I am sitting in front of my laptop enjoying a nice cup of coffee, I can’t
believe that I am working on the first 2017 issue of Hysteroscopy Newsletter. Yes,
2016 is gone! What a great year. Our hysteroscopy “revolution” is growing bigger
like a small snowball that is rolling downhill in a cold winter mountain. By now, our
snowball is unstoppable, it is about to become an avalanche of good things.
I am opening my mail box and I found sitting in my inbox one e-mail that is
highlighted as “very important” from Dr Luis Alonso, who we all know was the one
who let the snowball roll out of his hands, this time he is asking me for a challenge.
His e-mail reads: “Tony, resume en una página lo que sucedió en histeroscopia en el
año 2016. Felices fiestas, Luis” (Tony, in one page describe what has happened to
hysteroscopy in 2016. Happy holidays, Luis) My first thought was… he has been
drinking too much wine with good aged cheese these days. How am I going to
resume the best year for hysteroscopy in only one page?
Let me start, first Hysteroscopy Newsletter has grown exponentially, now we
reach many countries, leaders from all around the world are eager to collaborate and
the hysteroscopic community await every issue to download a great amount of
unbiased information from our Newsletter. (We have no financial conflict to
disclose). Second, the first Global Congress on Hysteroscopy was born. This colossal
event that will take place in the beautiful city of Barcelona from May 2nd to 5th 2017
is going to be a guaranteed sellout. A great deal of well-known world leaders will get
together to deliver the most updated information on hysteroscopy. Come to see first-
hand what is going on with this “hysteroscopic revolution”, there will be plenty of
videos and I guarantee you will go back home with your bag full of new tips and
tricks to improve your current hysteroscopic skills. Your patients will thank you for
that! Lastly, we just came back from the great city of Nagpur, India where the
Hysteroscopy Carnival took place. Thumbs up for Dr Sushma Deshmukh in putting
up such a great event. Faculty from America, Europe, Africa and Asia got together to
share their knowledge and enjoy the warm welcoming of the host. On that event the
latest hysteroscopy book was launched “Mastering the techniques in hysteroscopy” a
must have. Also, Dr Osama Shawki gave a great inspirational Ted Talk, showing his
“magic of hysteroscopy” and challenging the audience to become better at his art. We
left the room knowing that we can also do the “magic” with the hysteroscope.
The new year is here; rest assure that Hysteroscopy Newsletter will continue
to grow exponentially. We are committed to bring this ongoing hysteroscopy
“revolution” to the next level and we want you to be part of it. We invite you to
submit your articles, pictures, comment and critiques to our journal. We will all grow
together!
Happy New year 2017
Dr Jose “Tony” Carugno
University of Miami. USA
www.medtube.net
HYSTEROscopy group
www.twitter.com/hysteronews
www.facebook.com/hysteronews
FIND US ON
is an opened forum to all
professionals who want
to contribute with their
knowledge and even
share their doubts with a
word-wide gynecological
community
Editorial teaM
HYSTEROSCOPY

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