Ambulatory Hysteroscopy Evidence-based Guide to Diagnosis and Therapy

Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 20, No. 6, pp. 953 e975, 2006 doi:10.1016/j.bpobgyn.2006.06.004 available online at http://www.sciencedirect.com

8 Ambulatory hysteroscopy: evidence-based guide to diagnosis and therapy Shagaf H. Bakour*

MD, MRCOG

Consultant and Honorary Senior Lecturer in Obstetrics and Gynaecology City Hospital, Birmingham, UK 

Siaˆ n E. Jones

MB, BCh, FRCOG

Consultant Gynaecologist Bradford Royal Infirmary, Bradford, UK 

Peter O’Donovan

MD, Bch, BAO, FRCS (Eng), FRCOG

Consultant Obstetrician & Gynaecologist Bradford Royal Infirmary, Bradford, UK 

Healthcare providers are facing increasing demands for improvement in quality of life for patients. Improvements in service provision for women are being ensured by the introduction of minimally invasive technologies into all spheres of gynaecologic practice. Ambulatory hysteroscopy (direct endoscopic visualization of the endometrial cavity) is an extremely exciting and rapidly rapidly advancing advancing field of gynaec g ynaecologi ologicc practice. practice. It advanced advanced dramatically dramatically during the 1990s, shifting the focus in healthcare away from inpatient diagnosis and treatment. Hysteroscopy is used extensively in the evaluation of common gynaecological problems that were previously evaluated with blind and inaccurate techniques (e.g. premenopausal menstrual disorders, infertility and postmenopausal bleeding). It allows direct visualization of the uterine cavity and the opportunity for targeted biopsy, safe removal of endometrial polyps, and treatment of submucous fibroids, septa and adhesions. Ambulatory hysteroscopy is safe, with a low incidence of serious complications; it has a small failure rate. There is a general consensus that hysteroscopy is the current gold standard for evaluating intrauterine pathology, including submucous myomas, polyps, hyperplasia and cancer. Hysteroscopy in the ambulatory setting appears to have an accuracy and patient acceptability equivalent to inpatient hysteroscopy under general anaesthetic. The The prim primary ary goal goal of this this chap chapte terr is to prov provid ide e a high high-q -qua ualility ty,, evid eviden ence ce-b -bas ased ed text text on ambulatory diagnostic and operative hysteroscopy. The chapter includes in-depth analysis of 

* Corresponding author. Address: City Hospital, Birmingham, UK. Tel.: 121 507 5467. E-mail address: [email protected]  [email protected] (S.H. (S.H. Bakour). 1521-6934/$ - see front matter

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2006 Published by Elsevier Ltd.

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S. H. Bak Bakour our et et al al

the indication indicationss for outpatien outpatientt hystero hysteroscop scopyy, its contraindi contraindicatio cations, ns, the accuracy accuracy of diagnostic diagnostic hysteroscopy, relevant risk management issues and, training and teaching. Keywords: advanced hysteroscopy training; ambulatory; diagnostic test accuracy; nurse hysteroscopy; one-stop clinic; outpatient diagnostic and operative hysteroscopy; risk management.

Questions and Literature Sources Questions  Population: women with abnormal uterine bleeding  Interventions: ambulatory diagnostic and operative hysteroscopy (coil retrieval, polyp polypec ecto tom my, remo remova vall of subm submuc ucou ouss myo yoma ma,, en endo dome metri trial al abla ablati tion on,, and and sterilization)  Outcomes: feasibility, acceptability, success rate, effectiveness of therapeutic interventions with the impact on quality of women’s life, and accuracy of the test against gold standards Literature sources  Electronic databases: relevant articles were identified through searches of the Cochrane Library, Best Evidence, MEDLINE, and EMBASE (1970 e2005)  Manu Manual al sear search ch:: of bibl biblio iogra graph phie iess of kn know own n prim primary ary and and revi review ew arti article cles, s, personal files of articles available from the authors and contact with experts and manufacturers

INTRODUCTION Historical background

Pantaleoni performed the first ambulatory diagnostic and operative hysteroscopy in 1869; he used a Desmoreaux cystoscope to diagnose and treat a haemorrhagic uterine growth with silver nitrate. The greatest subsequent improvements in distension media took place in the early 1970s, and in 1979 Hamou revolutionized the field of hysteroscopy with improved visual optics and fine-diameter instruments (