In the 1970s, the holistic concept of surgical treatment gradually emerged, and the physiological state, social activities and mental outlook of patients became the important research content of surgical treatment, and with the intervention of high technology, the concept of minimally invasive and minimally invasive surgery gradually formed and heated up. As an important part of minimally invasive surgery, the development of hysteroscopy is changing the pattern of diagnosis and treatment of traditional gynecological diseases, which has the characteristics of small trauma ratio, high efficiency ratio, rapid postoperative recovery and non-removal of the uterus in line with the physiological and psychological requirements of patients, and has been developing rapidly in developed countries, and is rapidly catching up with the international pace in China. The latest advances and clinical applications of hysteroscopy are reviewed as follows.
1. Hysteroscopic diagnosis
1. 1 Assessment of the diagnostic value of hysteroscopy
1. 1. 1 Hysteroscopy for intrauterine lesions Hysteroscopy for direct visual biopsy of suspicious lesions is the gold standard for the diagnosis of abnormal uterine bleeding (Abnormal UterineBleeding, AUB). 96. 3 and 83. 1 %, respectively. The highest accuracy was for endometrial polyps and the worst was for endometrial hyperplasia. Regarding the relationship between hysteroscopic images of endometrial hyperplasia and pathological histology, Dotto et al [2] classified hysteroscopic images of the endometrium into five categories: normal, benign lesions, low-risk endometrial hyperplasia, high-risk endometrial hyperplasia and endometrial cancer.
Agostini et al. retrospectively analyzed 17 cases of atypical endometrial hyperplasia diagnosed by hysteroscopic histopathology of hysterectomized tissue blocks and 1 case of endometrial cancer diagnosed by hysterectomy. the risk of endometrial adenocarcinoma detected by hysteroscopic surgery for atypical endometrial hyperplasia was 5. 9 % (1/17). In conclusion, hysteroscopy is a safe, easy and effective method to evaluate intrauterine lesions and its accurate diagnosis depends on localized biopsy in suspected endometrial hyperplasia to identify or exclude serious intrauterine lesions by pathology.
1. 1. 2 Indications for hysteroscopy By comparing the diagnostic results of ultrasound with biopsy and biopsy with hysteroscopy, Hunter et al. suggested that hysteroscopy should be performed in premenopausal, perimenopausal and postmenopausal women on hormone supplementation therapy (HRT) with endometrial thickness >10 mm, in those with abnormal endometrial biopsy or recurrence of symptoms, or in postmenopausal women not on HRT with endometrial thickness ≥5 mm.
1.1.3 The value of hysteroscopy in in vitro fertilization (IVF)
Herrera examined 1286 infertile women with hysteroscopy, and 38% of failed IVF cases had hysteroscopic lesions. After treatment of these lesions, the pregnancy rate was similar to that of a normal uterine cavity. Endometritis is treated with antibiotics and 40% of pregnancies occur after one month. Therefore, hysteroscopy should be used as a routine examination before IVF to improve the pregnancy rate.
Deckardt et al. compared hysteroscopy, hysteroscopy and diagnostic curettage (D&C) in 1286 cases of perimenopausal and postmenopausal bleeding. 2.26%) were histologically diagnosed with endometrial cancer, of which 2 cases (7.14%) had endometrial thickness ≤5 mm, 10 cases (34.5%) were hysteroscopically misdiagnosed with endometrial cancer (sensitivity 65.52%, specificity 99.92%), and 1.4% were complications of D&C.
Rogerson et al. prospectively studied the accuracy of hysterosalpingography (SHSG) for the diagnosis of intrauterine lesions in double-blind versus hysteroscopic comparisons. The patients underwent hysterosonography followed by fiberoptic hysteroscopy. 70 of the 117 cases were women of childbearing age, 47 were menopausal women, 20 failed SHSG, 1 failed hysteroscopy, 6 failed both, and 90 completed both, of which 78 were consistent and 12 were inconsistent.
De Kroon et al. prospectively studied 180 cases of SHSG, 12 cases (6.7%) failed and 22 cases (12.2%) were undiagnosed. The uterine volume > 600 cm3 was the most likely predictor of failure and non-diagnosis. It is considered that SHSG can replace 84% of hysteroscopies and that hysteroscopy should be performed only when SHSG fails and/or is not diagnostic.
1. 3 Miniature hysteroscope Japanese miniature hysteroscope, the front end of the mirror is soft and easy to bend, the diameter is thin, the front end is straight, the field of view is 100°, the tip can be bent to the left and right each 100°, and the biopsy forceps have a gate to fix the position. These 6 functions are not as good as the rigid mirror. The indications are cervical stenosis, HRT and IVF patients. It can be performed without anesthesia or with any anesthesia, with little dilation and with gravity dilatation using 0.9% sodium chloride solution, which is well tolerated by patients and can be performed in an outpatient clinic or mobile station, with a diagnostic accuracy rate of 94%. Minor surgery such as polypectomy, tubal passage, IUD removal, endometrial removal, etc. can also be performed. If necessary, endometrial biopsies are taken.
A total of 35444 cases were performed in France, 55% of which were performed at the same time, 71% of which took less than 5 minutes, and 90% of which were tolerated without serious complications. The fiberoptic hysteroscope has a 120° view of the outer sheath, which allows to see the bilateral fallopian tubes with a 100° bend of the tip, a 1.2 mm operating orifice, access to 3 Fr of auxiliary instruments such as cell brushes, biopsy forceps, grasping forceps, tubal catheters, etc. The dilating fluid is 0.9% sodium chloride solution, which is instilled by gravity, eliminating the need for expensive pumps and avoiding the risk of intrauterine hypertension.
2. Hysteroscopic surgery
Banceanu et al. compared the reproductive prognosis of hysteroscopic and conventional surgical treatment of intrauterine lesions. 56 cases in the conventional group had a 50% (28/56) postoperative pregnancy rate and 16 cases (28.6%) were full term. In the hysteroscopic surgery group of 160 cases, the pregnancy rate was 78.8% (126/ 160) and 95 cases (59.4%) were full term. The reproductive prognosis of intrauterine anomalies treated by hysteroscopic surgery was significantly better than that of conventional surgery, making hysteroscopic surgery a very effective alternative.
2.1.1 Endometrial resection (TCRE) and endometrial removal (EA)
(Vilos et al [9] reviewed 10 patients with simple and complex endometrial hyperplasia with (or without) heterotypes diagnosed by hysteroscopy, 2 with hysterectomy and no residual endometrium in the specimen, and 8 with TCRE and pathology suggestive of atypical hyperplasia. At 1-9 years of follow-up, 7 cases were free of menstruation and were in good condition, while 1 case was free of menstruation and died of colon cancer 2 years after surgery. The authors suggest that skilled hysteroscopic electrosurgery may be an alternative to hysterectomy in patients with conditional follow-up of atypical hyperplasia. To investigate the accuracy of hysteroscopic endometrial resection for the diagnosis of endometrial adenocarcinoma in women with AUB, Vilos et al. retrospectively analyzed 13 cases of endometrial adenocarcinoma identified pathologically by TCRE for AUB. All patients survived 0.5-9 years after TCRE with no signs of cancer recurrence.
Regarding the factors of recurrence after TCRE, Perez2Medina et al. reported 286 cases of premenopausal women with heavy menstruation who had undergone TCRE in the absence of pharmacological treatment, and 75% of them benefited from this procedure at 47 months of follow-up. In summary, the factors that affect the prognosis of TCRE are the duration of follow-up, the age of the patient, the presence of adenomyosis, the lack of depth of endometrial excision and missed excision, and the increase of endoscopic pressure at the end of the operation to check for residual endometrium in the “blind zone” and “blind spot”. The “blind spot” refers to the two walls of the uterus, and the “blind spot” refers to the uterine horn, at the end of each operation, we must increase the expansion pressure to see the fallopian tube mouth, the “blind spot” uterine horn has been fully seen If there is any omission, the lateral wall of the uterus will be inspected along the tubal opening. It is believed that TCRE can be used as an intermediate transitional measure between pharmacological treatment and hysterectomy treatment.
The incidence of pregnancy was 2.39% (32/ 341), and 4 cases were ectopic pregnancies, accounting for 12.5% (4/ 32). The incidence of miscarriage, placental implantation, fetal growth restriction, and abnormal third stage of labor in post-TCRE pregnancies is increased, so it should be considered as a high-risk group and should be monitored.
2.1.2 Removal of foreign body from uterine cavity (TCRF) Residual fetal bone and endometrial ossification are rare, and Hsia Enlan reported that hysteroscopy is the treatment of choice for endometrial calcification, and only hysteroscopy can directly observe and remove the residual fetal bone instead of traditional blind scraping and hysterectomy. TCRF requires precise localization and removal to prevent perforation of the uterus, so the procedure should be performed under ultrasound and/or laparoscopic supervision.
2. 1. 3 Myomectomy (TCRM) Litta et al. reported that an oval incision was made with the Collins electrode in the endometrium covering the myoma, with the incision positioned at the base of the myoma turning toward the uterine wall until the myoma was exposed, and the myofibers around the myoma were cut, so that almost all of the myoma protruded into the uterine cavity, facilitating complete removal of the myoma. The average operative time was 27 minutes (10-45 minutes). This method is suitable for resection of most submucosal myomas located between the muscle walls. The five-step approach of cutting, clamping, twisting, pulling and delivery of the hysteroscopic electrosurgical myoma facilitates shortening the operative time and complete removal of the myoma.
Pace et al. reported that hysteroscopic resection was performed in 75 cases of uterine adhesions. 70 cases had normal uterine cavity after 2 months and 4 cases were operated for the second time. 28.7% to 53.6% pregnancy rate was observed after the operation.
2. 1. 5 Endometrial polypectomy (TCRP) Spiewankiewicz et al. reported that in 25 patients with infertility combined with endometrial polyps, 80% of pregnancies were achieved 12 months after TCRP, and pregnancy was not related to the size of the polyps.
Angell et al. reported a case of uterine abnormality found in the first pregnancy, which was diagnosed postpartum hysteroscopically as a longitudinal septum and cut open with cold scissors without complications, and HSG follow-up showed a small residual longitudinal septum. The uterine rupture of the pregnancy after TCRS was not related to the method of uterine formation, the presence of complications or careful follow-up.
With the widespread use of hysteroscopic surgery and the accumulation of experience, hysteroscopic surgery has become a safe, minimally invasive, easy-to-learn procedure with good surgical prognosis and few complications. Mettler et al. reported 726 cases of hysteroscopic surgery with 1. 65% morbidity, with false tract and uterine perforation being the most common acute complications and no distant complications. Among the 1952 hysteroscopic procedures, 623 cases of TCRE, 782 cases of TCRM, 422 cases of TCRP, 199 cases of TCRA, 90 cases of TCRS. 34 cases (1. 74%) had uterine perforation, of which 33 cases (97. 1%) were detected intraoperatively and treated promptly without sequelae.
The incidence of uterine perforation in TCRA was higher than that in other surgeries, and the difference was significant. In Bradley’s experience, preoperative application of misoprostol or alginate may reduce uterine perforation. The incidence of gas embolism in hysteroscopic surgery is 10 to 50%, but catastrophic consequences are rare, only 3/17000. Imasogie et al. reported a case of a 50-year-old woman with menorrhagia, in the lithotomy position, with head down 20° for EA and TCRP, who had a sudden drop in oxygen saturation to 87% at 15 minutes, and a drop in end-expiratory CO2 from 46 mmHg to 27 mmHg, with normal respiration of 11-12 breaths/day. The cardiovascular variables were stable, and the patient recovered immediately with 100% oxygen inhalation.
We diagnosed gas embolism based on oxygen saturation and end-expiratory CO2 drop. After all measures to prevent fluid overload and gas embolism had been implemented, we speculated that the gas produced by tissue combustion caused the gas embolism. The gas produced by combustion during hysteroscopy is mainly CO2, and the accumulation of gas increases the intrauterine pressure and encourages gas to enter the open venous sinus.
In recent years, due to the miniaturization of hysteroscopic instruments, advances in lighting systems, energy systems, uterine expansion systems, the application of imaging systems, the accumulation of practical experience and the depth of scientific research, hysteroscopy is already safe, effective and very mature technology, foreign applications have been very common, hysteroscopy can be carried out in mobile workstations, hysteroscopic surgery and one-day wards are becoming increasingly popular, and the country is catching up with the international The country is catching up with the international advanced pace. It is worth noting that the basic knowledge, basic theory and basic technical operation of hysteroscopy are different from traditional surgery, and when the selection of indications is inappropriate, the treatment is not comprehensive and there are many complications for inexperienced people. Therefore, while paying attention to the clinical progress of hysteroscopy
Therefore, while paying attention to the progress of clinical application of hysteroscopy, we should also pay attention to the learning and training of basic theory and basic technical operation of hysteroscopy.