Hysteroscopy Overview of systematic reviews

1. Hysteroscopy
Overview of systematic
reviews
Aboubakr
Elnashar
Benha university
hospital, EGYPT
ABOUBAKR ELNASHAR

2. WHAT IS THE BEST EVIDENCE?
ABOUBAKR ELNASHAR

3. What is a systematic review?
 A review of a clearly formulated question that
uses systematic and explicit methods to
1. identify, select and critically appraise relevant research
2. collect and analyse data from the studies that are
included in the review
(Cochrane Reviewers’ Handbook 4.1.5)
ABOUBAKR ELNASHAR

4. Systematic
review
Meta-analysis
Literature
review
What is Meta-Analysis?
The use of statistical techniques in a systematic review to
integrate the results of included studies.
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5. 2. OBJECTIVE
Review SR regarding hysteroscopy
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6. 3. METHODS
Pub med:
From 2006 till October 2016
Key words
•Hysteroscopy
•Systematic review
•Meta analysis
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7. 4. RESULTS
122 SR:
oRandomized controlled trials
oCase control studies
oSelf controlled studies
Classified into:
I. Preparation
II. Diagnostic hysteroscopy
III. Operative hysteroscopy
IV. Prevention of complications
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8. I. PREPARATION
Antibiotic prophylaxis
No advantage was found for, hysteroscopy.
(Morrill et al, 2013)
 Routine antibiotic prophylaxis is generally not
recommended, patients at risk for pelvic
infections should be screened and treated prior to
the procedure
(Pereira et al, 2016)
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9. II. DIAGNOSTIC HYSTEROSCOPY
1. Vaginoscopy:
Should be the standard technique for diagnostic
hysteroscopy (Grade A)
Using
(≤3.5mm sheath)(Grade A)
Rigid hysteroscope (Grade C)
N S distension medium (Grade C)
Without
Any anaesthesia(conscious sedation should not be routinely
used)
Cervical preparation (Grade B)
Vaginal disinfection
Antibiotic prophylaxy(Grade B).
(Cooper et al, 2010; French College of Gyn and Obst, 2014)ABOUBAKR ELNASHAR

10. Successful and significantly reduces pain, compared
with traditional techniques using a vaginal speculum
(Cooper et al, 2010)
No significant complications
An easy way to gain access to the cervical canal
An important tool to diagnose and treat vaginal
lesions.
(Sardo et al, 2016)
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11. 2. Diagnostic accuracy of hysteroscopy
Accurate in the diagnosis of IU abnormalities
(van Dongen et al, 2007)
High for:
Endometrial cancer
Polyps
Submucous myomas
Moderate for:
Endometrial hyperplasia
(Clark et al, 2002; Gkrozou et al, 2015)
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12. (Gkrozou et al, 2015)
SensitivityLesion
75.2%Endometrial hyperplasia
82.6%Endometrial cancer
95.4%Endometrial polyps
97.0%Submucous myomas
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13. 3. Comparison between histology of endometrial
hyperplasia obtained by:
uterine curettage
hysteroscopically guided biopsy, or
hysteroscopic endometrial resection and
subsequent results of hysterectomy
Uterine curettage or hysteroscopically guided biopsy
Underestimation of endometrial cancer:
inappropriate surgical procedures
(31.7% of tubal conservation and no abdominal exploration in 24.6% of the cases)
Hysteroscopic resection:
Reduced the risk of underdiagnosed endometrial
cancer
(Bourdel et al, 2016)
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14. 4. Hysteroscopy before IVF
Before the 1st trial of IVF?
(inSIGHT): multicentre, RCT
(Smit et al, 2016, Lancet)
750: normal TVS
Hysteroscopy (with treatment of any detected abnormalities)
before starting IVF, or
Immediate IVF
LBR did not differ significantly (55%)
Routine hysteroscopy does not improve LBR in
infertile women with a normal TVS before first IVF
treatment.
Women with a normal TVS should not be
offered routine hysteroscopy.
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15. Before IVF in women with RIF (2-4):
(TROPHY): multicentre, RCT (8 hospitals in the UK,
Belgium, Italy, and the Czech Republic)
350: hysteroscopy
352: control.
LBR: 29% in each group, no significant
difference between either group
(relative risk 1.0; 95% CI 0・79–1.25; p=0.96).
Outpatient hysteroscopy before IVF with a
normal TVS and a history of unsuccessful IVF
does not improve LBR.
(El-Toukhy , 2016, Lancet)
Trial of outpatient hysteroscopy
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16. III. OPERATIVE HYSTEROSCOPY
1. Removal of LNG-IUS with retracted strings due to
pregnancy
Combining hysteroscopy with US facilitates
removal.
(McCarthy et al, 2012)
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17. 2. Hysteroscopic morcellation Vs resection (traditional
electrocautery) for treatment of uterine cavitary lesions:
Lower incidence of:
Life-threatening complications:
fluid overload
uterine perforation
bleeding
(Haber et al, 2015)
Incomplete lesion removal.
Shorter operative time
Limitation:
Heterogeneity
Small sample size
(Shazly et al, 2016)
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18. 3. Hysteroscopic septoplasty
Uterine sptum ±: detrimental effect on:
pregnancy achievement
spontaneous abortion
obstetric outcome
Septoplasty
Reduced spontaneous abortion
(RR 0.37, 95% CI 0.25 to 0.55)
(Venetis et al, 2014)
Safe and effective: PR: 60%
LBR: 45%.
(Nouri et al, 2010)
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19. 4. Myomectomy
Fibroid ≤4 cm
marginally significant benefit compared with
expectant management
(RR = 1.9; 95% CI: 1.0-3.7).
(Bosteels et al, 2010)
CPR:
Fibroid:
21%
After myomectomy:
39%
(95% CI 21% to 58%): (odds ratio (OR) 2.44, 95% confidence interval
(CI) 0.97 to 6.17, P = 0.06, 94 women
very low quality evidence
(Cochrane SR, 2015)
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20. 5. Polypectomy:
For 16 mm :
Prior to IUI:
doubles PR
starting 3 months after polypectomy
[relative risk (RR) = 2.3; 95% confidence interval (CI): 1.6-3.2].
(Bosteels et al, 2010)
CPR:
simple diagnostic hysteroscopy:
28%
Polynectomy:
63%
(95% CI 50% to 76%)(OR 4.41, 95% CI 2.45 to 7.96, P <
0.00001, 204 women, moderate quality evidence).
(Cochrane sr, 2015)
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21. 6. Endometrial scratching in RIF
In the cycle prior to starting COS
improve pregnancy outcomes.
70% more likely to result in CP as opposed to
no treatment
2-times more likely to result in CP compared
with diagnostic hysterscopy.
(Potadar et al, 2012)
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22. 7. Niche resection
Rate of complications:
low.
AUB
improved in 87 to 100%.
Pregnancies
 were reported after therapy
sample sizes and follow-up: insufficient to
study fertility or pregnancy outcome
More evidence is needed before (surgical)
niche interventions are implemented in daily
practice.
(Voet et al, 2014)
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23. 8. Treating CSP
5 approaches depending on:
availability
severity of symptoms
surgical skills:
1. Resection through
1. TV approach
2. Laparoscopy
3. Hysteroscopy.
2. UAE + D& C and hysteroscopy
3. UAE + D &C
(Petersen et al, 2016)
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24. Hysteroscopy:
most frequently adopted 1st line approach.
Hysteroscopy and laparoscopic hysterotomy:
safe and efficient
Systemic methotrexate and D&C:
not recommended as 1st line approach
{high complication and hysterectomy rates}.
Hysterectomy
(%)
Success
rate (%)
Resolution
time(D)
Bleeding
(%)
0.039207Hysteroscopy
1185933UAE
2922028Lap Hysterotomy
496014Systemic MTX
7624651D&C
Pektas et al, 2016: 1674
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25. 9. Sterilization Essure(®):
After 3 months
 Pregnancy: rare
{1. no imaging follow-up
2. inadequate confirmation of placement or
occlusion}.
(Cleary et al, 2013)
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26. Hysteroscopic Vs Laparoscopic sterilization:
Lower:
PR (GRADE very low)
Complication rates (GRADE very low)
No significant improvement in patient satisfaction
(GRADE very low).
(McMartin; 2013)
Safe, permanent, irreversible
less invasive.
(Hurskainen et al, 2010)
more expensive {cost of the microinserts}
less costly {shorter recovery time required}.
(Toronto Health Economic, 2013)
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27. 10. For management of hydrosalpinx
Before IVF:
effective
(Arora et al, 2014)
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28. 11. Endometrial ablation
Newer techniques
technically easier
Success rates and complication profiles:
compare favourably with TCRE
(Lethaby et al, Cochrane, SR, 2005)
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29. 12. RPOC:
Hysteroscopic resection Vs D&C:
Less:
IUAs: 13 vs 30%
Incomplete evacuation:1 vs 29%
Similar
Conception,OPR, LBR and miscarriage rates
Tendency toward earlier conception
HR may be a preferable surgical treatment of
RPOC
(Hooker et al, 2016)
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30. IV. PREVENTION OF COMPLICATIONS
1. Adhesions
IUAs at any 2nd -look hysteroscopy
Anti-adhesion therapy:
fewer when compared with no treatment or
placebo
(OR 0.36, 95% CI 0.20 to 0.64, P value = 0.0005,no statistical
heterogeneity (Chi(2) = 2.65, df = 5 (P value = 0.75), I(2) = 0%).
Number needed to treat for an additional benefit:
9 (95% CI 6 to 20).
LBR
No evidence of differences between anti-
adhesion therapy and no treatment or placebo
(Cochrane SR, 2015)
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31. IUD Vs IU balloon:
No evidence of differences with respect to IUAs
at 2nd -look hysteroscopy
(OR 1.23, 95% CI 0.64 to 2.37, P value = 0.54, one study, 162 women;
very low-quality evidence).
The quality of evidence:
low or very low for all outcomes.
Clinical effectiveness of anti-adhesion treatment
for improving reproductive outcomes or for
decreasing IUAs: uncertain.
(Cochrane SR, 2015)
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32. Surgical techniques which reduce the use of
electrosurgery:
should be preferred whenever possible
(Level of evidence: 4)
Early 2nd -look hysteroscopy:
effective as preventive & therapeutic
Gel barriers:
significant effect on IUA prevention
{higher adhesiveness and prolonged residence
time on the injured surface}
(Level of evidence: 1b)
(Sardo et al, 2016)
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33. Hormonal and antibiotic therapy
difficult to evaluate
{it has been used in association with other
prevention strategies in most studies}.
(Sardo et al, 2016)
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34. Gel:
Hyaluronic acid, polyethylene oxide-sodium carboxymethyl cellulose
significant reduction of IU adhesion
Estrogen
no decrease in IU adhesion
lack of definitive evidence
that any treatment is effective in preventing post
hysteroscopy IU adhesion.
{significant heterogeneity
high risk of bias}
(Healy et al, 2016)
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35. 2. Cancer cell dissemination
Hysteroscopy in patients with endometrial cancer
hints a risk for cancer cell dissemination within the
peritoneal cavity.
(Polyzos et al, 2010)
The risk:
statistically significantly associated with the use of a liquid
medium for uterine cavity distention
not associated with early-stage disease.
No evidence
to support an association between preoperative
hysteroscopic examination and worse prognosis.
(Chang et al, 2011)
Diagnostic or operative hysteroscopy
is allowed when an endometrial cancer is
suspected
(Grade B).(French College of Gynand Obs, 2014)ABOUBAKR ELNASHAR

36. ABOUBAKR ELNASHAR
You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura

37. Thank you
ABOUBAKR ELNASHAR