Thursday, November 24, 2011

Indispensable technique becomes disposable to boost its use

A new single-use disposable hysteroscope (http://hcp.obgyn.net/conference-insider/aagl2011/content/article/1760982/1976908 and http://hcp.obgyn.net/conference-insider/aagl2011/content/article/1760982/1980724) is being investigated by Dr Paul Indman in hopes that, once FDA-approved for commercial use, it will encourage more gynecologists to carry out diagnostic hysteroscopy in an office setting. Dr Indman believes that it is just as important for a gynaecologist to be able to look inside the uterus as it is for an ear doctor to look inside the ear. While nothing seems more evident, fewer than 10% of Obgyns in the US are trained to perform in-office hysteroscopy. This is due to a number of factors including the lengthy preparation and costs of setting up traditional hysteroscopy. Conventional ones are large and cumbersome, and need to be sterilised before each use. Besides the actual hysteroscope, a video camera, monitor and lighting are necessary to perform the procedure. The new hysteroscope is hand-held with a plastic disposable hysteroscope and a reusable handle that has a monitor, light source and a high resolution camera the size of a pin-head incorporated into it. Currently, plastic disposable curettes are used for D&C, so there is no basis for the concern that this will increase pollution to the environment. Hopefully it will be available in the near future and more gynaecologists and fertility specialists will take an interest in using this less-invasive technology to improve diagnosis of women’s health problems. Note: There is another similar device that is available for ~ 300 USD: http://medgadget.com/2007/01/femsuites_femey.html

(Disclaimer:  It is up to medical professionals who are trained in hysteroscopy to assess the performance of these products. I am not in a position to endorse them).
Hysteroscopy is gold-standard method for the evaluation of the uterine cavity to diagnose conditions such as intrauterine adhesions, endometrial polyps and fibroids and structural malformations such as septate uterus. Operative hysteroscopy is used for treating the diagnosed condition where microscissors or other instruments are used for tissue dissection. A resectoscope is a hysteroscope which is equipped with loop that uses electrical energy for cutting, although the loop can be used without thermal energy as a mechanical cutting tool.

Operative hysteroscopy is also used by some gynecologists to remove retained products of conception in select patients and/or situations. It may raise eyebrows among some medicaI professionals who have been trained to rely on blind curettage (D&C) for a wide range of diagnostic and therapeutic indications, but there should be no reason why it is not routinely used in Gynecology, including for ERPC when expectant or medical management fail to completely empty the uterus after a miscarriage, instead of blind curettage. There are a number of publications describing hysteroscopic curettage (1-7) for removing RPOC. Blind curettage is the most common cause of intrauterine adhesions (Asherman’s syndrome), which leads to infertility necessitating corrective surgery. The lack of Obgyns suitably trained in hysteroscopy is another reason why hysteroscopy has not replaced the D&C. Unfortunately, the use of hysteroscopy in Gynecology is even declining from the time it was first invented in the 1980s. Hysteroscopy is the logical progression from blind scraping invented over a century ago. It’s hard to believe that over a century later this comparatively rudimentary technique for women is still being used. Minimally invasive techniques are routinely used in Urology (e.g. in-office cytoscopy). Women also need to empower themselves and support more precise and safer methods by choosing hysteroscopy over blind curettage. Most gynaecologists perform blind curettage without giving a second thought to any long term risks involved. They may not be aware of the future problems it has caused their patients unless the patient specifically contacts them to tell them.  
Finally, this article by Dr Keith Isaacson(8) is not new, but it outlines the uses of hysteroscopy, compares office and hospital hysteroscopy and dispels the common misconceptions about it that are hindering its widespread use, such as poor reimbursements and a difficult learning curve. http://www.obpmedical.com/v/vspfiles/assets/images/office%20hysteroscopy%20-%20a%20valuable%20but%20under-%20utilized%20technique.pdf


REFERENCES
  1. Nicopoullos JDM, Treharne A, Raza A and Richardson R. The use of a hysteroscopic resectoscope for repeat evacuation of retained products of conception procedures: a case series. Gynecological Surgery. 2010; 7(2):163-6. Abstract http://www.springerlink.com/content/384125gp81055401/  
  2. M.H. Emanuel, F.W. Jansen and D. Schoot The Hysteroscopic Morcellator, an Effective Technique for the Removal of Residual Trophoblastic Tissue Journal of Minimally Invasive Gynecology Volume 16, Issue 6, Supplement 1, 2009, Page S85. 
  3. Faivre E, Deffieux X, Mrazguia C, Gervaise A, Chauveaud-Lambling A, Frydman R, Fernandez H. Hysteroscopic management of residual trophoblastic tissue and reproductive outcome: a pilot study. J Minim Invasive Gynecol. 2009 Jul-Aug;16(4):487-90. Abstract www.ncbi.nlm.nih.gov/pubmed/19573826
  4. T. Dankert & M. Vleugels. Hysteroscopic resection of retained placental tissue:a feasibility study Gynecol Surg . 2008; 5:121–124. Free article www.springerlink.com/index/w4021j484l211057.pdf  
  5. F. Leone, T. Bignardi, C. Marciante, E. Bertazzoli, P. Mustoni, E. Ferrazzi and L. DSC 74: Hysteroscopy for Selective Removal of Residual Trophoblastic Tissue. Journal of Minimally Invasive Gynecology 2005;12(5), Supplement 1: 30-1.
  6. Cohen SB, Kalter-Ferber A, Weisz BS, Zalel Y, Seidman DS, Mashiach S, Lidor AL, Zolti M and Goldenberg M. Hysteroscopy May Be the Method of Choice for Management of Residual Trophoblastic Tissue. The Journal of the American Association of Gynecologic Laparoscopists 2001;8(2):199-202. Abstract
  7. Goldenberg, M, Schiff E, Achiron, R. Lipitz, S. Mashiach, S. Managing residual trophoblastic tissue. Hysteroscopy for directing curettage. J Reprod Med. 1997;42(1)26-8. Abstract www.ncbi.nlm.nih.gov/pubmed/9018641
  8. Isaacson K. Office hysteroscopy: a valuable but under-utilized technique.Current Opinion in Obstetrics and Gynecology 2002, 14:381-385. Free article http://www.obpmedical.com/v/vspfiles/assets/images/office%20hysteroscopy%20-%20a%20valuable%20but%20under-%20utilized%20technique.pdf

No comments:

Post a Comment

Post a Comment