Hysteroscopy: Polyp and Leiomyoma Resection

Description

Operative hysteroscopy enables the visual inspection and treatment of intracavitary and submucosal myometrial leiomyomata, which incorporates the use of mechanical or electrosurgical instruments.

Indications

Known or suspected endometrial polyp(s) or symptomatic intracavitary, submucosal, or intramural leiomyomata where there is a significant proportion of the lesion that protrudes into the uterine cavity.

Contraindications

Patients who are medically unstable, viable (desired) pregnancy, known cervical or uterine cancer, active pelvic inflammatory disease, blood dyscrasia, active herpetic infection.

Required Equipment

• Sterile gloves and operative drapes

• Skin preparation materials (generally an iodine-based antibacterial solution such as povidone-iodine [Betadine] unless the patient is allergic)

• Vaginal speculum or weighted vaginal speculum with Deaver or similar retractors

• Single tooth tenaculum or sponge stick

• Blunt uterine sound (optional)

• Hysteroscope (rigid) with light source. Operating hysteroscopes include an outer sheath which surrounds channels for the telescope, distending media inflow and outflow, and operative instruments.

• Distending media. For operative procedures using monopolar electrosurgical instruments, a nonconductive fluid (eg, glycine) is required; bipolar electrosurgical procedures may use an isotonic fluid (eg, normal saline); mechanical procedures (eg, biopsy or morcellation) are generally done using saline.

• Equipment for infusing and monitoring the uterine distending media.

• Hysteroscopes with greater than 5-mm outside diameter (most operating sets) require mechanical cervical dilation via graduated cervical dilators (Hegar, Pratt, Rocket, Heaney, Hank, or similar; Goodell dilators are generally not preferred because of an increased risk of cervical laceration). Preoperative dilation is generally preferred and may be accomplished with the aid of cervical ripening agents (eg, misoprostol, 200–400 mcg PO or intravaginally) or osmotic dilators (eg, laminaria).

• Video, photographic, or digital image capture equipment may be attached to the hysteroscope as desired (optional).

• If an electrosurgical technique is chosen, appropriate operative electrodes, electrosurgical generator, patient return electrode with monitor, and isolated circuitry should be available.

• Histology fixative (10% formalin) in containers.

• An assistant is advantageous.

• Premedication with a nonsteroidal antiinflammatory drug can reduce postoperative pain.

• Cycle optimization and endometrial thinning can be accomplished using combination oral contraceptives for a few weeks prior to the procedure.

• Antibiotic prophylaxis is not recommended for routine hysteroscopic procedures.