Office Hysteroscopy   part II procedures MPH Vleugels  Riverland hospital Tiel
Hysteroscopic procedures in the office <ul><li>diagnostic procedures </li></ul><ul><li>minor surgical procedures </li></ul...
Hysteroscopic procedures in the office <ul><ul><ul><li>Versapoint ® </li></ul></ul></ul>
“ 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     ...
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%...
Versapoint: polyp size / operation time  M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
Versapoint:   Conclusions for the office <ul><li>small </li></ul><ul><li>bipolar electrode:  coagulation </li></ul><ul><li...
Versapoint:  results knowing the specific characteristics = small electrodes,  ACCEPTABLE OPERATION TIME 30-45 MIN ???? FI...
Retrospective analysis 2yrs surgery; 92%  of all FIBROIDS TYPE 0  OR  TYPE I 47%  of all FIBROIDS TYPE 0 84%  of all FIBRO...
operation   settings on OPD <ul><li>continous flow hysteroscope 4.2or 4.9 mm  </li></ul><ul><li>control in/outflow = resor...
Versapoint on the OPD Trics for removal polyps <ul><li>Use twizzle </li></ul><ul><li>cut into pieces </li></ul><ul><li>pre...
Versapoint on the OPD &quot;painting like an artist&quot; Trics for removal fibroid
<ul><li>PREMEDICATION: </li></ul><ul><li>diclofenac supp  2-3 x 100 mg </li></ul><ul><li>paracetamol   1 x 1000 mg </li></...
Office Based Hysteroscopic Surgery with a Bipolar Electrosurgery System in Normal saline VERSAPOINT
Take home messages………...
<ul><li>Surgery L.A./non anaesthesia: </li></ul><ul><li>informed consent/good communication </li></ul><ul><li>criterium of...
<ul><li>Surgery general  anaesthesia/spinal: </li></ul><ul><li>patients after cervical surgery </li></ul><ul><li>POLYPS > ...
Hysteroscopic procedures in the office <ul><li>Essure ®  sterilisation </li></ul>
Hysteroscopic procedures in the office <ul><li>A new method of female hysteroscopic sterilisation </li></ul><ul><li>Market...
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 V...
The dutch appraoch
Hysteroscopic procedures in the office Can this procedure done on the OPD without any anaesthesia?  which method? * proced...
Flowchart essure sterilisation Intake informed consent gyn examin ultrasound data recording Planning < CD 10 Premedication...
Dutch protocol <ul><li>Planning procedure < 10 e  cycle day </li></ul><ul><ul><ul><li>In case of spontaneous cycle or OAC;...
Essure on the OPD;  method without anaesthesia <ul><li>“ Bettocchi”approach=no speculum, no tenaculum, no local anaesthesi...
Evaluation of pain  (Visual Analoque Score; 0-10 ): average 2,5  ±2,5   (0-8)     median 2,0 two patients got local anaest...
Hysteroscopic procedures in the office Dutch experience; First 273 patients procedure time     introduction  of scope  til...
Averaged Procedure time related to parity; Multiparae;  10.3 minutes Nulliparae;  15.3 minutes Procedure time related to p...
Crude failure rate; 7.4% True failure rate=after exclusion Asherman  5.3% Failure rate related to parity (trainings clinic...
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 ...
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% P...
Hysteroscopic procedures in the office <ul><li>X HSG only required: </li></ul><ul><li>in unsatisfactory placements </li></...
The dutch experience Patients leave straight after  Treatment for work or other activities
Hysteroscopic procedures in the office <ul><li>It takes twelve weeks for the tubes to be completely occluded. </li></ul><u...
<ul><li>Conditions   </li></ul><ul><li>good  (diagnostic ) hysteroscopist  </li></ul><ul><li>  operating without local ana...
<ul><li>take home message </li></ul><ul><li>Essure has been developed to be used without anaesthesia  /without IV sedation...
Placement failures: 14  (8%) partial  Syndrome of Asherman  5 tubal spasme   2 failure of Essure device ( former type) 1 u...
Hysteroscopic procedures in the office
 
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  • Hysteroscopy 0

    1. 1. Office Hysteroscopy part II procedures MPH Vleugels Riverland hospital Tiel
    2. 2. Hysteroscopic procedures in the office <ul><li>diagnostic procedures </li></ul><ul><li>minor surgical procedures </li></ul><ul><ul><ul><li>conventional instruments </li></ul></ul></ul><ul><ul><ul><li>Versapoint ® </li></ul></ul></ul><ul><li>Essure ® sterilisation </li></ul>
    3. 3. Hysteroscopic procedures in the office <ul><ul><ul><li>Versapoint ® </li></ul></ul></ul>
    4. 4. “ how long does the procedure take…???? Hysteroscopic procedures in the office
    5. 5. 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
    6. 6. Versapoint: fibroid size / operation time M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
    7. 7. Type intramural extension 0 none I <50% II >50% Submuceus Myoma: Classification
    8. 8. 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
    9. 9. Versapoint: polyp size / operation time M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office
    10. 10. Versapoint: Conclusions for the office <ul><li>small </li></ul><ul><li>bipolar electrode: coagulation </li></ul><ul><li>cutting vaporisation </li></ul><ul><li>active in normal saline </li></ul><ul><li>fits in 5mm scope </li></ul><ul><li>learningcurve 3-5 procedures for diagn. scopist </li></ul><ul><li>safe as long as the principles of hysteroscopy are respected </li></ul>Vleugels MPH gyn endoscopy 2002
    11. 11. 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
    12. 12. 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?
    13. 13. operation settings on OPD <ul><li>continous flow hysteroscope 4.2or 4.9 mm </li></ul><ul><li>control in/outflow = resorption normal saline </li></ul><ul><li>cutting (polyps) = Versapoint twizzle electrode </li></ul><ul><li>vaporizing (fibroid) = Versapoint spring electrode </li></ul><ul><li>start always presettings VC 1 with small electrodes </li></ul><ul><li>and decrease to VC2 or VC 3 when touching the wall </li></ul><ul><li>most important setting = well communicating nurse </li></ul>
    14. 14. Versapoint on the OPD Trics for removal polyps <ul><li>Use twizzle </li></ul><ul><li>cut into pieces </li></ul><ul><li>present to pathologist!! </li></ul><ul><li>Do not vaporize </li></ul>
    15. 15. Versapoint on the OPD &quot;painting like an artist&quot; Trics for removal fibroid
    16. 16. <ul><li>PREMEDICATION: </li></ul><ul><li>diclofenac supp 2-3 x 100 mg </li></ul><ul><li>paracetamol 1 x 1000 mg </li></ul><ul><li>(diazepam 1 x 10 mg) </li></ul><ul><li>IF NECESSARY: </li></ul><ul><li>paracervical block lidocain 0.5% + epinephrine 1/200.000 </li></ul><ul><li>MANDATORY IS A GOOD SOCIAL INTELLIGENT NURSE </li></ul><ul><li>and doctor!!! </li></ul>Versapoint: Analgesia on OPD
    17. 17. Office Based Hysteroscopic Surgery with a Bipolar Electrosurgery System in Normal saline VERSAPOINT
    18. 18. Take home messages………...
    19. 19. <ul><li>Surgery L.A./non anaesthesia: </li></ul><ul><li>informed consent/good communication </li></ul><ul><li>criterium of speculum examination ( cutner,erian gyn.endo 1996) </li></ul><ul><li>POLYPS < 3 CM </li></ul><ul><li>FIBROIDS < 2 CM type 0 and I </li></ul><ul><li>SYNECHIAE CLASSICATION WAMSTEKER < III </li></ul>patient selection for bipolar hysteroscopic surgery in the office Hysteroscopic procedures in the office
    20. 20. <ul><li>Surgery general anaesthesia/spinal: </li></ul><ul><li>patients after cervical surgery </li></ul><ul><li>POLYPS > 3 CM </li></ul><ul><li>FIBROIDS  2 CM type 0 and I </li></ul><ul><li>FIBROIDS type II </li></ul><ul><li>SYNECHIAE CLASSICATION WAMSTEKER  III </li></ul><ul><li>SEPTUM </li></ul>patient selection for bipolar hysteroscopic surgery not in the office Hysteroscopic procedures in the office
    21. 21. Hysteroscopic procedures in the office <ul><li>Essure ® sterilisation </li></ul>
    22. 22. Hysteroscopic procedures in the office <ul><li>A new method of female hysteroscopic sterilisation </li></ul><ul><li>Marketed and sold by Conceptus, Inc. </li></ul><ul><li>Approved by FDA on Nov. 4 th , 2002 </li></ul>Essure ® sterilisation
    23. 23. Hysteroscopic procedures in the office Essure procedure= Bettocchi vaginal approach
    24. 24. Hysteroscopic procedures in the office
    25. 25. 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
    26. 26. The dutch appraoch
    27. 27. 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
    28. 28. 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
    29. 29. Dutch protocol <ul><li>Planning procedure < 10 e cycle day </li></ul><ul><ul><ul><li>In case of spontaneous cycle or OAC; no difference!! </li></ul></ul></ul><ul><ul><ul><li>No need to remove the IUD unless a difficult procedure </li></ul></ul></ul><ul><li>Premedication </li></ul><ul><ul><ul><li>Diclofenac 100mg sup at their wake up </li></ul></ul></ul><ul><ul><ul><li>Diclofenac 100mg sup+1000mg paracetamol orally leaving home </li></ul></ul></ul><ul><li>Good breakfast/lunch!! Partner present </li></ul>Hysteroscopic procedures in the office
    30. 30. Essure on the OPD; method without anaesthesia <ul><li>“ Bettocchi”approach=no speculum, no tenaculum, no local anaesthesia, no sedation </li></ul><ul><li>Dilatation warm Normal saline 0.9%, low pressure, minimal slow movements </li></ul>* Study A n=173 accepted Hysteroscopic procedures in the office
    31. 31. 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
    32. 32. Hysteroscopic procedures in the office Dutch experience; First 273 patients procedure time introduction of scope till removal
    33. 33. 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
    34. 34. 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
    35. 35. 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
    36. 36. Hysteroscopic procedures in the office Control after 3 months by transvaginal ultrasound!!!
    37. 37. No X-Ray No- HSG HSG HSG X- Ray A B c Predictive value of US?? Hysteroscopic procedures in the office
    38. 38. 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
    39. 39. Hysteroscopic procedures in the office <ul><li>X HSG only required: </li></ul><ul><li>in unsatisfactory placements </li></ul><ul><li>after difficult procedures </li></ul><ul><li>Pelvic X-ray only required: </li></ul><ul><li>missing device by ultrasound </li></ul>13 th Annual Congress of the ESGE, Cagliari, Sardinia In all other cases an ultrasound is sufficient
    40. 40. The dutch experience Patients leave straight after Treatment for work or other activities
    41. 41. Hysteroscopic procedures in the office <ul><li>It takes twelve weeks for the tubes to be completely occluded. </li></ul><ul><li>Patient must stay on alternative contraception for the twelve weeks </li></ul>After the Procedure
    42. 42. <ul><li>Conditions </li></ul><ul><li>good (diagnostic ) hysteroscopist </li></ul><ul><li> operating without local anaesthesia; </li></ul><ul><ul><ul><ul><ul><li>BETTER OUTCOME THAN LOCAL/GENERAL; Ubeda, Lopez, Dhanaut studies </li></ul></ul></ul></ul></ul><ul><li> create appropiate conditions </li></ul><ul><ul><ul><ul><ul><li>i.e. social intelligent doctor,nurse </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>i.e. nice surrounding, quiet, music! </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>i.e. work quickly,fluently </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>i.e. good breakfast </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>i.e. extra monitor for patient </li></ul></ul></ul></ul></ul>Hysteroscopic procedures in the office
    43. 43. <ul><li>take home message </li></ul><ul><li>Essure has been developed to be used without anaesthesia /without IV sedation in out pat clinic/center,…. </li></ul><ul><li>Using the correct instruments on the proper way after training of the whole team = doctor and assistent,…. </li></ul><ul><li>Respecting the limits of the patient=she is guiding you, then.. </li></ul><ul><li>Control can be done by ultrasound unless a correct protocol has been followed </li></ul><ul><li>Efficacy, safety and satisfaction of patient and the team will be high </li></ul>Hysteroscopic procedures in the office
    44. 44. 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 <ul><li>Thank you, for your attention </li></ul><ul><li>In case you need more information… </li></ul><ul><li>Training for Essure protocol…. </li></ul><ul><ul><ul><li>[email_address] </li></ul></ul></ul>
    45. 45. Hysteroscopic procedures in the office

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