1. Office Hysteroscopy part II procedures MPH Vleugels Riverland hospital Tiel

4. “ how long does the procedure take…???? Hysteroscopic procedures in the office

5. Versapoint: CLINICAL RESULTS ANAESTHESIA totaL general local none polyps 95 24 41 30 fibroids 51 14 23 14 septa 8 8 -- -- synechia 7 6 -- 1 others 2 -- 1 1 total 163 51 65 46 M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office

6. Versapoint: fibroid size / operation time M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office

7. Type intramural extension 0 none I <50% II >50% Submuceus Myoma: Classification

8. Versapoint:fibroids comparison general/local anaesthesia none/local general number: 37 14 type 0 19 (51%) 5 (36%) type I 16 (43%) 7 (50%) type II 2 (6%) 2 (14%) M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office

9. Versapoint: polyp size / operation time M Vleugels Gyn.Endoscopy 2001 10 Hysteroscopic procedures in the office

11. Versapoint: results knowing the specific characteristics = small electrodes, ACCEPTABLE OPERATION TIME 30-45 MIN ???? FIBROID <2CM POLYP <2CM HOW MUCH OF THE PATHOLOGY CAN BE OPERATED WITH THIS ELECTRODE ON THE OFFICE? Hysteroscopic procedures in the office

12. Retrospective analysis 2yrs surgery; 92% of all FIBROIDS TYPE 0 OR TYPE I 47% of all FIBROIDS TYPE 0 84% of all FIBROIDS SMALLER THAN 3 CM 95% of all POLYPS SMALLER THAN 4 CM 70 - 80% can be operated in the office Hysteroscopic procedures in the office How much pathology can be operated in the office?

15. Versapoint on the OPD &quot;painting like an artist&quot; Trics for removal fibroid

17. Office Based Hysteroscopic Surgery with a Bipolar Electrosurgery System in Normal saline VERSAPOINT

18. Take home messages………...

23. Hysteroscopic procedures in the office Essure procedure= Bettocchi vaginal approach

24. Hysteroscopic procedures in the office

25. Hysteroscopic procedures in the office Ideal Placement Spanning the Uterotubal Junction (UTJ) With Deployed Micro-insert Visible in the Uterine Cavity UTJ 3-8 expanded outer coils visible in uterine cavity Hysteroscopic Image 2 4 3 1 4 expanded outer coils Last coil not expanded Uterus Cervix

26. The dutch appraoch

27. Hysteroscopic procedures in the office Can this procedure done on the OPD without any anaesthesia? which method? * procedure time? * pain experience? * placement failure rate * patient satisfaction? ** control after 3 months? *** * Study A n=173; ** study B n=273 *** study C n=160; all studies submitted

28. Flowchart essure sterilisation Intake informed consent gyn examin ultrasound data recording Planning < CD 10 Premedication procedure OPDepartm. Data recording pain score list Ultrasound TVS HSG 1-2-5 followup T=0 T=12wks T=12 wks Hysteroscopic procedures in the office

31. Evaluation of pain (Visual Analoque Score; 0-10 ): average 2,5 ±2,5 (0-8) median 2,0 two patients got local anaesthesia ; 2/900 Average amongst nulli; 5.2! Dutch experience; Results 2 first clinics Hysteroscopic procedures in the office

32. Hysteroscopic procedures in the office Dutch experience; First 273 patients procedure time introduction of scope till removal

33. Averaged Procedure time related to parity; Multiparae; 10.3 minutes Nulliparae; 15.3 minutes Procedure time related to placement failure rate; Succes placement; 9.8 minutes Failure placement; 24!! minutes Hysteroscopic procedures in the office procedure time Multicenter data netherlands n=1021 21 clinics in 2005

34. Crude failure rate; 7.4% True failure rate=after exclusion Asherman 5.3% Failure rate related to parity (trainings clinic n=297 2002-2004) failure rate nulliparae 32% failure rate multiparae 5.1% Failure rate Multicenter data netherlands n=1021 21 clinics in 2005 Hysteroscopic procedures in the office

35. How do we control the effect? X ray to see whether the device is in abdomen? In the uterus? HSG to prove occlusion of the tubes?? Hysteroscopic procedures in the office

36. Hysteroscopic procedures in the office Control after 3 months by transvaginal ultrasound!!!

37. No X-Ray No- HSG HSG HSG X- Ray A B c Predictive value of US?? Hysteroscopic procedures in the office

38. Hysteroscopic procedures in the office Diagnostic value of Transvaginal Ultrasound Sensitivity: 50% Specifity: 94.6% Pos. predictive value: 99.3 (95% CI: 98.0% - 100.6%) Neg. predictive value: 11% (95% CI:6.0% - 16.0%) Veersema S, Vleugels MPH: fert ster. Dec 2005

40. The dutch experience Patients leave straight after Treatment for work or other activities

45. Hysteroscopic procedures in the office