HYSTEROSCOPY CHANGING TRENDS.

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HYSTEROSCOPY CHANGING TRENDS.

• MOUNIR M F ELHAO,
• PROFESSOR,AIN SHAMS UNIVERSITY
• EARLY CANCER DETECTION UNIT,
• GYNE-ONCOLOGY UNIT.

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Early Cancer Detection Unit1981-2007 Prof.
Dr. M. B. Sammour1981-1991

• Prof. Dr. M. Ezz Eldin Azzam1992 Prof. Dr. M.
  Elshourbaguy2002
• Prof.Mahmoud Yussef.
• 2006

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Prof.Dr. A Eltawil

• Dr. Soheir Bassiouny
• Dr. Amal Alloub
• Dr. Hala Elsallaly
• Dr. Ragia Fahmy
• Dr. Iman Kamal
• Dr. Sahar Ezzelarab (Epidemiology / Statistics)
• Dr. Khaled Kamel
• Dr. Reem Abdel Azim
• Dr. Nahla Awad
• Dr. Ghada Nabil
• Dr. Alaa Rashed (Obst. Gyn)

• Prof. Dr. Magda Hassan
• Prof. Dr. Ragaa Amin
• Prof. Dr. Magda A.Salam
• Prof. Dr. Laila Nabegh
• Prof. Dr. Zeinab Shehab

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The crossing tunnel to mysterious woumb.
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Panoramic View,Tubal ostea.
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• Saline 0.9.Best, office,Bipolar.
• Glucose 5 .
• Glycene.Best operative Unipolar(lt1000.)
• Hyskon.Not any more.(DIC.)
• Glucose 10 ,Hyperglycaemia.

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25 Dextrose a safe and clear distension medium.

• 76 cases done with 25 dextrose for uterine
  distetion as a safe and clear medium,However in
  recent experience its seems unsafe due to
  operative procedure opening deep sinuses and
  intravasation of the fluid and causing
  hyperglycaemia.
• Elhao,1988.

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Cervical dilatation.

• Women treated with lidocaine spray had
  significantly less pain. Uterine cavity
  abnormality might be associated with a higher
  degree of pain during hysteroscopy
• D. SORIANO, MD, S. AJAJ, MD, T. CHUONG, MD, B.
  DEVAL, MD, A. FAUCONNIER, MD and E. DARAÏ, MD,
  PhD
• Abdelmaaboud...Acetic Acid

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IDENTIFICATION OF OVULATION BY PANORAMIC
HYSTEROSCOPY.

• Endometrial thickness.
• Vascularity. . ( sensitivity
  90)
• Prominence of glands
• Surface roughness.
• Tubal ostea Appearance.
• ( sensitivity was 81.9 )
• (M Elhao et al,1992.)

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Hysteroscopic Classification of IUS.

• 844 infertile women
• Fine adhesions.
• Coarse adhesion.
• Dense adhesions,Tubular cavity.
• Complete Occlusion.
• (Sammour,Elhao,Yehya Saleh, Congres mondiale d
  hysteroscopy,Paris (1993).

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Major and Minor IUS.

• Correction of (Grade 3 4)
• With the use of electro cautary needle under
  hysteroscopic guidance resulted into\
• very poor pregnancy rates.(2cases only)
• Both of them resuted into missed abortion.

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IUS nightmare.

• In 32 cases (43.2 ) G12
• In 44 cases (56.8) G 34
• Recurrence almost 1/3 of cases.
• Maily in G34,
• Mainly after puerpural sepsis.
• Elhao,Lamii,Elnazer, Hamza.MD Thesis(1996)

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IUS.
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Missed Threads of IUCDs,a new technique of
hysteroscopic extraction.

• Using the telescope of the hysteroscope and a
  mini crocodile forceps.
• From 286 cases of missed threads,236 were found
  to be intrauterine and were either successfully
  extracted (220cases).or left in place after
  withdrawal of the threads(16 cases.)
• (Elhao,1990)

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Missed IUCDs.

• 50 cases of missed IUCDs threads,hysteroscopy was
  successful in extraction of 100(20 cases) of
  IUCDs
• While DC was successful in only 90 of cases.
• Maged ,Elhao et al.1989.

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IUCD related AUB.

• 72 patient wearing IUCDs,41 cases complaining of
  irregular uterine bleeding.while 31 cases as
  controls.
• In the group of AUB 27 cases of the 41 cases had
  local pathplogy or abnormal position of IUCDs
• Only one case of the control had local
  pathological lesion.
• Elhao et al,1989

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CS Scar.

• In 50 cases of previous CS there were
• Scar not detected 11
• Fibrotic white band 16
• Granulation tissue 13
• Minute defect. 03
• Large defect. 05
• Cervicat scar 02
• What should we do?
• Yehya,Sammour,Elhao (1990)

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The use of hysteroscopy in MFD.
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UNICORNUATE UTERUS.
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UNICORNUATE UTERUS.
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Septum resection. One of the most satisfactory
procedures in hysteroscopic surgery and gynecology

• 2-3 of the population.
• 20 of repeated miscarriages.
• Since Edstrom in 1974,described hysteroscopic
  resection of uterine septum the technique was
  practiced
• Elhao,Sammour and Elgammal,MS thesis,(1993.)
• .

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Hysteroscopic myomectomy,when and how?

• Symptomatic SMF are satisfactorily resected
  hysteroscopically with the least possible
  morbidity , restoring fertility and curing
  menstrual disturbances.(93-97)
• Shalakany,Hussein,Amer,and Elhao.(1998)

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Routine hysteroscopy for patients with high risk
of uterine malignancy.

• On fifty patients with high risk for uterine
  malignancy,(Diabetic , hypertensive , obese,
  infertile, low parity),
• A negative hysteroscopic finding was considerted
  conclusive of absence of uterine pathology
• Panoramic hysteroscopy is a valid alternative of
  traditional D and C.
• (Sammour , Elhao , Eissa , Khalifa and Elmogazi.
  (1992),

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Recurrent abnormal uterine bleeding.

• Cases were 2 or more DCs were performed for
  irregular uterine bleeding.(33 patients.)
• Hysteroscopy revealed abnormal intracavitary
  pathology in 81.8 of cases examined.
• 10 myomas,
• 4 polyps,
• 11 hyperplasia,
• 1 atrophy
• and cancer in 1 case.
• Makhlouf and Elhao,1989.

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Hysteroscopic management of MFD for over 25
years..

• First described by ELDSTROM in 1974
• Hysteroscopic management of lateral fusion
  defects,septate,subseptate ,partial bicornuate
  and uterus bicollis with or without septate
  vagina was done since early eighties.obstetric
  performance was markedly improved after this
  procedure.
• Electric Knife ,loop,or cold scissors.
• Unipola or bipolar diathermy.
• With or without anesthesia.
• Elhao , Sammour (several studies.)

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TUBAL OSTEUM.
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PTB CANNULATION.
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Hysteroscopic catheterisation of the fallopian
tube in proximal tubal block.

• Patients infertile for at least one year with
  proven PTB by HSG and or Laparoscopy (witout
  evidence of other major explanation for their
  infertility.)were subjected to tubal
  cannulation.using one of many cannulation kits.
• The study showed recanalisation rate of 77.7
• M Sabri,K Lamii and M Elhao,(MD thesis,1996.)
• Recently,with more experience,a trial on
  antichlamidial therapy for three month is
  worthwhile before cannulation.

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Effect of preoperative GnRHa or Progestin on
endoscopic endometrial resection.

• From october 1993 to october 1996.,80 patients
  prepared for endometrial resection .25 depot
  provera,25 GnRHa and 30 patients non treatment
  group.
• Conclusions were that progestins were cheaper and
  better than no treament but with more side
  effects.GnRHa gave better control of menorrhagia
  ,more effective reduction of endometrial
  thickness and reduction of uterine size ,less
  fluid absorption.
• Shalaby,Hussein,Elhoussiny and Elhao,(1998.)
• With more experience.No Need For preoperative
  preparations.

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The use of Pour 8 (vasopressin analogue.)prior to
endometrial resection.

• Seems to have an important role during the
  procedure.
• Fluid absorption was less,bleeding was less and
  vision was better in the pour-8 group.
• Elhao,Fateen,Mostafa and Taha, 1998).

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IUS with office.

• Use of scissors under office and routine
  hysteroscopy gives far more better results
• Elhao et al,2006-2007.(ongoing study .)

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Amnion graft in severe IUS

• Amer (2006 ).

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PERFORATION DURING HYSTEROSCOPIC PROCEDURE.
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O perative O ffice H ysteroscopy
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The most important requirement for successful
hysteroscopy

• is satisfactory distension of the uterus.
• While many different media have been used,
  recent advances in equipment have greatly
  simplified the use of saline for diagnostic and
  simple operative hysteroscopy.

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• TECNIQUE
• a 5 mm continuous flow office hysteroscope
  (Bettocchi Office Hysteroscope size 5 Karl Storz
  GmbH Co., Tuttlingen, Germany). The scope is
  based on a rod lens system with a diameter of 2.9
  mm and a 30 view.

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• The continuous flow sheath has an oval profile.
• the mechanical instruments used were grasping
  forceps with teeth and scissors (Karl Storz GmbH
  Co.).

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• This eliminates the need to change sheaths, or
  start with a larger diameter operative sheath,
  when anticipating the need to remove polyps, cut
  adhesions, or do biopsies under direct vision.

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• To avoid pain during the procedure Intrauterine
  pressure was maintained at a constant 40-60 mmHg
  using an electronic pump for irrigation and
  aspiration (Endomat Karl Storz GmbH Co.).

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INDICATIONS OF OFFICE HYSTEROSCOPY IN 147 CASES.
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OUTCOME OF 453 OFFICE DIAGNOSTIC OPERATIVE
HYSTEROSCOPY.
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OUTCOME OF 189 PROCEDURE OF OPERATIVE
HYSTEROSCOPY.
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CONCLUSIONS.

• Minor operative procedures are possible,using
  scissors or bipolar diathermy.
• All degrees of IUS are better treated with mini
  scissors and office hysteroscopy.
• Hysteroscopic endometrial resection and large
  myomas are in need for General anaesthesia and
  9mm resectoscope.

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Conclusions

• Hysteroscopy is a very important tool in many
  gynecological conditions.

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CONCLUSION

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• Office hysteroscopy made possible by the
  development of small instruments. Proper patient
  selection and training of office personnel to
  minimize complications and maximize efficacy.
• Lindheim SR, Kavic S, Shulman SV, Sauer MV
  (2005)

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CONCLUSIONS.

• Office hysteroscopy is a time-efficient and
  cost-effective procedure,