Hysteroscopic Endometrial Resection Versus Laparoscopic Supracervical Hysterectomy for Abnormal Uterine Bleeding: Long-term Follow-up of a Randomized Trial (2023)

To compare the operative outcomes of patients undergoing either single-port or multiport laparoscopic hysterectomy (LH).

Two hundred fifty-six women scheduled for LH for symptomatic myoma and/or adenomyosis from 8 tertiary teaching hospitals were randomized to single-port or multiport groups. Primary outcome was conversion and/or complication proportion of the planned procedure to determine whether the success proportion of the single-port approach was not inferior to that of the multiport approach. Secondary outcomes were postoperative pain and operative scar.

Demographic parameters including age, body mass index, parity, and history of vaginal and cesarean delivery were comparable between the 2 groups. The primary outcome of a combined conversion and/or complication rate was similar between the single-port and multiport groups at 8% and 10.3%, respectively. Conversions were similar between the groups with 4% of single-port cases and .8% of multiport cases. Transfusions were the most frequent complication required in 4.0% of single-port cases and 7.9% of multiport cases, with no difference between the groups. Concerning secondary outcomes, postoperative pain score and patient and observer scar assessment were not different between the 2 groups. Although not a specific outcome measure, there was no difference between the groups in blood loss, operative time, and postoperative hospital stay.

Single-port LH is not inferior to multiport LH in terms of conversion and/or complications rates, including transfusion. However, the single-port approach did not have any advantage over multiport LH with regard to painorcosmeticoutcomes.These findings were demonstrated by multi-institutional surgeons in Korea.

To evaluate the safety and efficacy of a new crosslinked hyaluronan (NCH) gel in reducing postoperative adhesions.

Randomized controlled trial (Canadian Task Force classification I).

Seven departments of obstetrics and gynecology in China.

A total of 216 women scheduled for gynecologic laparoscopic surgery for primary removal of adhesions, myomas, ovarian cysts, or endometriotic cysts.

Patients were randomized to receive either NCH gel or saline with 1:1 allocation.

All patients were evaluated using a modified American Fertility Society (mAFS) scoring system for the incidence, extent, and severity of pre-existing and postoperative adhesions at the 10 anatomic sites of ovaries/tubes and at the expanded 23 or 24 anatomic sites throughout the abdominopelvic cavity by laparoscopy. A total of 215 randomized patients were treated with either saline solution (108 of 108) or NCH gel (107 of 108), composing the full analysis set (FAS), and 196 patients (94 of 108 in the saline control group and 102 of 108 in the NCH gel group) completed the entire study, composing the per protocol set (PPS). The postoperative incidence of moderate or severe adhesions evaluated at the 10 sites (the primary endpoint for efficacy) was 27.7% in the control group and 9.8% in the NCH gel group, a difference of 14.4% (95% confidence interval [CI], 2.6%–20.6%) in the PPS, and 37.0% in the control group and 14.0% in the NCH gel group, a difference of 20.0% (95% CI, 8.9%–26.8%) in the FAS. The postoperative incidence of moderate or severe adhesions evaluated at the 24 sites was also significantly lower in the NCH gel group compared with the control group (5.9% vs 14.9%; p=.036) in the PPS. Also in the PPS, the NCH gel group had significantly lower postoperative adhesion scores of severity, extent, and mAFS: 60.0%, 50.8%, and 76.9%, respectively (median scores of the 10 sites; p=.002) and 48.5%, 50.0%, and 72.2% (median scores of the 24 sites; p=.001) lower than those recorded in the control group. No serious adverse events were observed, and the safety profile of NCH gel was comparable to that of saline control.

This study demonstrates that NCH gel is safe and significantly reduces adnexal adhesion formation and global adhesion formation throughout the abdominopelvic cavity after gynecologic laparoscopic surgery.

To compare parenterally administered moderate sedation and paracervical block versus general anesthesia during day-case operative hysteroscopy for polypectomy in terms of patients' postoperative pain perception, operating time, and postoperative drug administration.

A pilot study (Canadian Task Force classification I).

A university hospital.

Women undergoing hysteroscopic polypectomy procedures (N=56).

Hysteroscopic polypectomy with general anesthesia or moderate parenteral sedation and paracervical block.

The patients were divided into 2 groups: 26 underwent general anesthesia (group 1), and 30 were submitted to moderate parenteral sedation and a paracervical block (group 2). General anesthesia was induced with the laryngeal mask airway with propofol (1% 1–2.5mg/kg) and fentanyl (1–2μg/kg) and maintained with an infusion of propofol (2% 3–5mg/kg/h). After the procedure, patients in the general anesthesia group received postoperative analgesic medication with paracetamol (20mg/kg) and ketorolac (0.6mg/kg) or tramadol (2–3mg/kg). The group receiving moderate parenterally sedation and a paracervical block received a paracervical block with mepivacaine (1% 10mL) and lidocaine (2% 10mL) and received fentanyl (1μg/kg) and propofol (1% 1–3mg/kg/h) maintaining spontaneous breathing. A blind observer recorded the operative time and the discomfort of patients using a 4-step scale (0–3). The postoperative pain assessment was performed 3hours after the procedure with a self-administered validated tool, the Brief Pain Inventory. We found that women receiving moderate parenteral sedation and a paracervical block perceived significantly less pain in daily activity (p<.001), walking (p<.001), daily work (p<.001), relations with others (p=.007), sleep (p<.001), and pain contrasting enjoyment of life (p<.001). The total amount of time spent in the operating room in group 2 was significantly lower than in group 1 (p<.014).

Moderate sedation plus a paracervical block for operative hysteroscopy is associated with reduced pain perception and a shorter operative time.

To compare hysteroscopic morcellation with bipolar resectoscopy for removal of endometrial polyps, in terms of procedure time, peri- and postoperative adverse events, tissue availability, and short-term effectiveness.

Multicenter, open label, randomized controlled trial (Canadian Task Force classification I).

Day surgery setting of a teaching and a university hospital.

Women with larger (≥1cm) endometrial polyps.

Hysteroscopic morcellation with the TRUCLEAR 8.0 Tissue Removal System or bipolar resectoscopy with a rigid 8.5-mm bipolar resectoscope.

Eighty-four women were included in the intention-to-treat analysis. Medianoperating time was 4.0min (range: 2.5–7.1) and 6.0min (range: 3.8–11.7) in the hysteroscopic morcellation and resectoscopy groups, respectively. Operating time was reduced by 38% (95% confidence interval: 5%–60%; p=.028) in the hysteroscopic morcellation group. Procedure time, which was defined as the sum of the installation and operating time, tended to be less for the hysteroscopic morcellation group (median 9.5min [range: 7.6–12.2] vs 12.2min [range: 8.8–16.0]; p=.072). Perforation occurred at dilation or hysteroscope (re)introduction in 3 patients of the resectoscopy group, resulting in procedure discontinuation or prolongation of hospital stay. Perforation occurred at dilation in 1 patient in the hysteroscopic morcellation group; however, the procedure was successfully completed. Postoperatively, 2 patients of the hysteroscopic morcellation group were diagnosed with a urinary tract infection. Tissue was available for pathology analysis in all patients, except for 2 patients in the resectoscopy group in whom the procedure was discontinued due to perforation.

Hysteroscopic morcellation is a fast, effective, and safe alternative to bipolar resectoscopy for removal of endometrial polyps.