UPDATE MINIMALLY INVASIVE SURGERY When a problematic cervix or distorted anatomy makes it impossible to enter the uterus for hysteroscopy or other offi ce procedures, a few good tools and techniques can help. ›› Amy Garcia, MD Dr. Garcia is Director of the Center for Women’s Surgery and Assistant Professor, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM. She serves on the OBG Management Board of Editors. Dr. Garcia reports that she is a consultant to Conceptus and Ethicon Women’s Health and Urology and a speaker for Conceptus. ervical stenosis and diffi cult uterine and er expense of the operating room (OR); and Cvaginal anatomy ®poseDowden a challenge for theHealth avert the Media need for general anesthesia. gynecologist who needs access to the cervix In this fi rst Update on Minimally Invasive and uterus to evaluate pathology. Overcom- Surgery, I will: ing thisCopyright hurdle requiresFor apersonal careful, considered use only• describe the continuing shift from the IN THIS approach to avoid the complications of di- OR to offi ce for many gynecologic pro- ARTICLE lation, such as laceration, creation of a false cedures Common causes passage, uterine perforation, and failed pro- • review recent data on cervical softening of cervical cedures. Care and consideration also ensure • outline the components of mechanical stenosis a successful and comfortable procedure; save dilation page 29 the patient a great deal of time and the high- • off er tips on pain relief. Prerequisites for mechanical dilation Need for cervical access should not page 29 prohibit offi ce-based procedures How to straighten a fl exed uterus Cervical access is critical to increase the begun to move from the outpatient envi- page 30 percentage of procedures performed in the ronment into the offi ce as well, upping the offi ce setting. Th e offi ce has long been the number of offi ce procedures that require ideal environment for minor procedures safe access to the endometrial cavity. such as endometrial biopsy, dilation and For example, hysteroscopic tubal oc- curettage, diagnostic hysteroscopy, hystero- clusion (Essure) is performed transcervi- sonography, and insertion of an intrauterine cally, thereby eliminating all incisions and device—but diffi culty traversing the cervix the need for general anesthesia. Approxi- has relegated many of these procedures to mately 50% of all Essure sterilization proce- the OR. dures performed in the United States today CERVICAL DILATION Minor procedures such as tubal ster- are done in an offi ce, and that percentage is PAGE 34 ilization and endometrial ablation have expected to rise to 60% in 2009.1 22 OBG Management | April 2009 | Vol. 21 No. 4 For mass reproduction, content licensing and permissions contact Dowden Health Media. 22_OBGM0409 22 3/23/09 9:14:56 AM TABLE Size of the instrument varies across endometrial ablation systems Instrument Diameter Instrument Diameter ThermaChoice 5 mm NovaSure 7.2 mm (uterine balloon therapy) Her Option 5 mm Hydro 7.8 mm (cryoablation ThermAblator therapy) Th e smallest operative hysteroscopes offi ce.2–5 Cervical dilation requirements for that allow for placement of Essure coils have these devices range from 5 to 7.8 mm, mak- an outer-sheath diameter between 5 and 6 ing cervical access paramount (TABLE). mm. Even with such small diameters, cervi- A number of measures, such as cervical cal dilation is sometimes needed. softening and mechanical dilation, can ease Endometrial ablation off ers women dilation in an offi ce setting so that a stenotic who have menorrhagia a minimally inva- cervix no longer requires an OR for the pro- sive option for treatment. Several FDA- cedure to be completed. Successful in-offi ce approved devices are used safely in the cervical dilation also greatly reduces cost. New data back effi cacy of vaginal misoprostol for cervical softening The vaginal route of misoprostol da Costa AR, Pinto-Neto AM, Amorim M, Paiva LH, activated by the drug, especially in the uterus. administration has Scavuzzi A, Schettini J. Use of misoprostol prior to hys- Pharmacokinetic studies suggest that fewer side effects teroscopy in postmenopausal women: a randomized, the oral route of misoprostol has the shortest placebo-controlled clinical trial. J Minim Invasive Gyne- than the oral route— interval to peak serum concentration (within col. 2008;15:67–73. plus longer duration 30 minutes of ingestion), but that concentra- Waddell G, Desindes S, Takser L, Bequchemin M, Bes- and three times tion declines within 1 hour. Th e vaginal route, sett P. Cervical ripening using vaginal misoprostol before the bioavailability hysteroscopy: a double-blind randomized trial. J Minim on the other hand, has fewer side eff ects, Invasive Gynecol. 2008;15:739–744. with longer duration and approximately 6,7 Uckuyu A, Ozcimen E, Sevinc FC, Zeyneloglu HB. Effi - three times the bioavailability. Peak values cacy of vaginal misoprostol before hysteroscopy for cer- are equal to those of orally administered vical priming in patients who have undergone cesarean misoprostol. Th ey are attained at 60 minutes, section and no vaginal deliveries. J Minim Invasive Gy- then decline slowly, reaching 50% of peak necol. 2008;15:472–475. values by 240 minutes. Serum concentration Valente EP, Amorim MM, da Costa AR, de Miranda VD. remains elevated, improving effi cacy. Vaginal misoprostol prior to diagnostic hysteroscopy in patients of reproductive age: a randomized clinical I recommend an interval of 4 to 12 hours trial. J Minim Invasive Gynecol. 2008;15:452–458. between vaginal placement and the start of the procedure. A synthetic analog of prostaglandin E1, misoprostol is thought to act on the extracel- Vaginal route is clearly effective in lular matrix of the cervix, leading to water premenopausal women absorption, neutrophil collagenase release, In premenopausal women, several recent and cervical softening. Smooth muscle is randomized clinical trials show that vaginal CONTINUED ON PAGE 29 obgmanagement.com Vol. 21 No. 4 | April 2009 | OBG Management 23 23_OBGM0409 23 3/23/09 9:15:01 AM UPDATE Minimally invasive surgery misoprostol, administered before hysteros- copy, not only decreases pain and the force Common causes of cervical and amount of dilation needed, but also re- stenosis duces complications of cervical dilation.8 As Uckuyu and colleagues observe, these fi nd- Frequent causes of stenosis include: ings are consistent in nulliparous women Loop electrosurgical excision procedure, who have a history of cesarean delivery and conization, and laser vaporization — In one who receive 400 μg of vaginal misoprostol 6 series, 43% of cases of cervical stenosis re- to 12 hours before hysteroscopy. sulted from one of these procedures, with a Several studies found no improve- recurrence rate of 14%.11 ment in ease of dilation or operative time in menopausal women who received miso- Scarring of the external os — Common in prostol before hysteroscopy.9,10 However, in the parous cervix. Usually, only minimal dila- their randomized, placebo-controlled trial, tion is needed; the remainder of the cervix is traversed easily. da Costa and colleagues found that women who received 200 μg of vaginal misoprostol 8 Narrow or closed external os — Common in hours before hysteroscopy had a signifi cant menopausal women and increasingly com- decrease in intraprocedural pain associated mon in nulligravid and nulliparous women as with cervical dilation. the rate of elective cesarean delivery rises. In these cases, both the endocervical canal and Recommended protocol internal os are narrow, necessitating dilation through the entire length of the cervix. For women at signifi cant risk of cervical ste- nosis, give 400 μg of intravaginal misoprostol Genital atrophy — In postmenopausal wom- approximately 12 hours before the sched- en, cervical stenosis as a result of genital at- uled procedure. Th e patient should begin rophy is associated with pain upon cervical round-the-clock use of a nonsteroidal anti- dilation. The situation generally necessitates local anesthesia.12 infl ammatory drug (NSAID) an hour before The recommended insertion of the misoprostol tablets. protocol for intra- Side eff ects of vaginal and oral misopro- vaginal misoprostol stol include occasional diarrhea, abdominal Although you may sometimes fi nd an is 400 μg about cramping, uterine bleeding, and pyrexia. incompletely dissolved tablet within the 12 hours before Th ese eff ects are usually mild and limited.8 vagina, active medication usually has been the scheduled Concomitant administration of NSAIDs re- absorbed, leaving the less soluble vehicle procedure duces or eliminates these side eff ects. behind. When mechanical dilation is necessary, a few prerequisites can make a diff erence By assessing each patient carefully, the anterior lip of the cervix, has several advan- gynecologist can customize the intervention. tages. Countertraction against the dilating Accordingly, it is wise to have multiple types instrument can facilitate more controlled of dilators accessible to accommodate vary- placement of the dilator, preventing perfora- ing clinical needs and anatomic scenarios. tion of the uterus. Th is maneuver is especial- Begin by stabilizing the cervix. Use of ly useful when the cervical canal and internal a single-toothed tenaculum, placed on the os are tight or resistant. CONTINUED ON PAGE 30 obgmanagement.com Vol. 21 No. 4 | April 2009 | OBG Management 29 29_OBGM0409 29 3/23/09 9:15:05 AM UPDATE Minimally invasive surgery FIGURE 1 Straighten a fl exed uterus before dilating the cervix Anteverted uterus, fl exed Anteverted uterus, straightened Retroverted uterus, fl exed Retroverted uterus, straightened When the uterus is fl exed, creating acute angulation at the cervicouterine junction, it can be diffi cult to move the dilator through the internal os. By placing a tenaculum at the 12 o’clock position on the cervix of an anteverted uterus, or 6 o’clock on a retroverted uterus, and applying outward traction, you can straighten the distorted canal.