In-Office Hysteroscopy Surgery: Tools, Techniques & Post-Op Care

[Dr. Amy Park]
Circling back to the office hysteroscopy, one of the big things that people are talking about now is regarding cervical manipulation like IUD placement and pain control. Do you often do a paracervical block and what's your philosophy on that? Then also regarding the financial incentives, I know now office hysteroscopy gives a lot of RVUs and then transitioning that OR diagnostic hysteroscopy to the office. You live through that transition. I'm just curious about what your philosophy is on the pain and the tricks that you do for the office.

[Dr. Linda Bradley]
I think preparation, preparation, preparation, and patients being informed of what they're going to do. Now, there's different hysteroscopes. Each of us is going to like what we like for diagnosis. It's like if you're a golfer, you have your clubs that you like. If you are a skier, you have your skis that you like. If you bowl, they could have three 10-pound, 15-pound balls, but there's something that you like.

My workhorse in my office for diagnosis is a flexible hysteroscope. It is 3.2 millimeters. There are names of other disposable hysteroscopes that I've tried, but I think in my hands, these skis work for me. This bowling ball works for me. Yes, there are others and everybody should try. The flexible scope, usually, it's 3.2 millimeters. You don't have to dilate the patient. I used to put a tenaculum on and sound everybody. I don't do any of that. I have my patients to eat before coming.

If we know that they're coming, we have them take an NSAID if they're allowed to or Tylenol. The nurses prep them. We tell them that it's brief. It's usually very comfortable. I do have a paper early on for a visual analog. Most of the patients have very low pain scores and so do other physicians. At one point, I was also very proud to have been one of the first physicians to do hysteroscopic sterilization in the country with Essure. Of course, that's gone now.

I went to Mexico to train women that were having hysterectomies. Immediately, we put the devices in. They had the hysterectomies, made sure we were doing it properly, and then it came back to the US. At the Cleveland Clinic, I was a part of that clinical trial that was ultimately FDA-approved. We started doing those in the office. I'm being very honest. I can tell you what protocols are. I haven't put a paracervical block in probably 20 years.

I don't use them. If they're young, multiple leaps, cones, all C-sections, I have them use Cytotec or misoprostol by mouth, 400 micrograms the night before, or if they're menopausal. I think I can talk with you about pain regimens. The risk of a vagal-vagal is so low. It's just very, very low. I think there are doctors that use larger scopes, that use rigid scopes, that may need to do the paracervical with the 0.25% Marcaine with the deep paracervical blocks.

You're asking me my opinion for the things that I've done even when I started to do Essure and the hysteroscopic sterilization in the office. They ate before coming. We might give Toradol the night before, 12 hours. I might say take 600 of Motrin two or three times a day the day before to help with the prostaglandin release and all of that. That's just me. There are others who give Valium. There's others that have a driver that use a Marcaine spray.

There's all kinds of things that are used. Sometimes, if you ask me, putting in these paracervical blocks, some people use epi, and then they get the racing heart. Sometimes just all this other stuff we do, to me, creates more of an issue. I don't do paracervical block tray. I don't have one. "Where does she keep her medicine?" We don't have it. Now, what we are going to be doing, and I can publicly say this because we just had a meeting on Monday, we're going to be trialing several newer devices that will allow us to do larger polyps.

I would never personally do a myoma in the office. I would not, personally for me, retained products in the office because of absorption and bleeding. There may be some things like the polyps, which are very common, or things like that in the office. These devices might be a little bit larger, but I've also read and talked to physicians that are using them, the preparation, eating, and NSAID.

I don't give Valium. I don't give Demerol or an opioid to the patients. We do the pelvic, trauma-informed care kind of thing. I'm not going to force any of this on someone who's had incest, domestic violence, sexual violence. As easy as it might seem for some patients, it's better to be done in the operating room. We have to listen to our patients and be very patient-centric.

[Dr. Mark Hoffman]
You were talking earlier about blind D&Cs, you're like, "No more of those," you say. What are you using now? If you're going to do an endometrial sampling in the operating room, you're not doing a cure, what are you using and how are you evaluating endometrial pathology and how are you treating endometrial pathology in the operating room?

[Dr. Linda Bradley]
That's a good question. Almost all of my patients have already had a diagnostic hysteroscopy or an SIS in the office. By tradition, they always, always have, say, a pipelle in the office. When I bring them to the OR, like yesterday, the hysteroscope that you use, the tissue retrieval system, I use tissue retrieval systems for soft things, polyps, retained products. Fibroids, I only use the bipolar resectoscope. That's just me. You're speaking with me. There are people who love the tissue retrieval systems for fibroids. I do not think that they get into, always getting the entire fibroid out. I think there are very few type 0s. There are many more type 1 and type 2 fibroids, which I think personally with the tissue retrieval system is hard to remove.

What I do, like the lady's yesterday, I take out the polyp, the bigger thing, that 3-centimeter polyp, take that out with my tissue retrieval system. They take the sock out. I finish it. They put another sock in. Then I do what I call an uninterrupted, visually directed endometrial curettage with my tissue retrieval system. You have to sometimes let your uterine pressure down so that the uterine wall falls right into your space and that you haven't also artificially pushed the fibroid, a sessile fibroid flat that you missed something.

I usually do two separate specimens. There was a case a couple of months ago I looked in. It was a clear fibroid, an older woman, a clear polyp, and then near her lower uterine segment, something "just didn't look right." It looked more friable. I took three separate specimens. Once you get the fibroid out, keep your scope inside, put your foot on the pedal, and suck out all that fluid so that your tubing has 250 cc's of saline. You don't want to contaminate it. I take out that, put another sock in. Now, polyp near the tuberosity on the left. Take that out, run my fluids, and still my scope is in.

Then the last I saw this area, it just didn't "look right." I tell my patients my eyes are not a microscope. What I need to know is that this is not atrophy. It turns out the cancer was in the lower uterine segment "polypoid vascular," the yellow plaques that you might see. The fibroid and the polyp could have just been present in a passenger and not the problem. The problem for that lady was the cancer in the lower uterine segment. You can take as many biopsies as you want, just make sure that you keep that scope in, put your foot on the pedal, run that so you get out pushing that clear fluid back into the trap, i.e. the sock. Then the nurse just changes and she labels it, whatever it is. That's how.

Yes, I don't put a curette in and that's my trick question of my residents. We do the procedure and then I'll say, "Well, what do we need to do next?" They look back at the table, "Oh, you need to do a curettage." I say, "Well, tell me why. Tell me more." You have just visually gone all the way around. What more are you going to get with your curette, except a perf, okay? There's just no reason.

[Dr. Mark Hoffman]
You're not mowing the lawn here with the device. You're not just sampling or are you?

[Dr. Linda Bradley]:
I do. No, I do a full anterior wall, posterior wall. Yes
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You cannot get every millimeter but like yesterday, how the tubal ostia can be very concave. You get up in that little area. I've picked up cancers. It's not in your biopsy or curettage would never get up. Some people have a very deep-looking tubal ostia. You know what I'm saying? That's why endometrial ablations don't work because it doesn't get up there and burn all that endometrium as it's going out to the tubes. Then they get hematometra. Then they get retrograde bleeding. Then they get swollen bloody tubes, they get endometriosis, and they have cyclical pain.

No, I do a visually directed and I told the residents in my op notes, "Don't you ever put D&C on my patients, okay?" The way that we do this, it is labeled exam under anesthesia, dilation of cervix, hysteroscopically directed endometrial polypectomy, and hysteroscopically directed visual endometrial curettage. If I retire one day, people want to go back and look at what I've done, I never ever, almost ever use a curette. They can just take that off my table.

[Dr. Mark Hoffman]
You're doing directed biopsies and what else are you doing?

[Dr. Linda Bradley]:
When we do, we're trying to push this through now for retained products of conception. Why are you sucking the whole uterus? Suction curette for retained products, what business do we give to the reproductive endocrinologist? Asherman's, most Asherman's are caused by what? Retained products, doing a "D&C suction" of a missed abortion after postpartum. Well, postpartum hemorrhages are different, but you have a woman that's delivered, six, eight weeks later she's still bleeding. She's been on two or three birth control pills. You better look in there. It could be the smallest little piece of retained products. They bleed just like polyps. These things don't have to be that big.

[Dr. Mark Hoffman]
Are you using a hysteroscopic morcellator for that tissue?

[Dr. Linda Bradley]
Yes, absolutely, the retrieval system. Yes, for my retained products, I don't do OB. I haven't done it in decades, but I see a number of patients with retained products, yes, that were referred in.

[Dr. Mark Hoffman]
Let's talk about fibroids. The thing that I'm most curious about. You said you took 20 plus fibroids out of someone hysteroscopically, and I need to see this. I need to understand how that happens. Are you getting MRIs on these patients and seeing where they all are? How do you work them up? How do you address, how do you decide what fibroids to take? How do you know how far to go? You're going from below, right? You don't have the visualization of the outside, the serosa, of your depth. How do you deal with these tough cases?

[Dr. Linda Bradley]
Usually, if you're doing SIS or if they have a lot of fibroids, you can't distend the cavity, and they're bleeding. I do an MRI. Again, start with easy. Sometimes the uterus just doesn't distend. You might have an MRI, but with this issue, I think the uterus remodels itself during your surgery. All of my patients with fibroids, preoperatively, they all get oral misoprostol the night before. Helps with cervical dilation and makes the uterus contract. Sometimes you think that the patient has one fibroid or two, sometimes that uterus has contracted and more things have pushed in. I do a lot of variability in my intrauterine pressure, pressure's up, pressure's down. It leads to a massage of the uterus. Sometimes these intramural fibroids will pluck themselves into the cavity.

What do I do? I want to know the patient's fertility wishes because if they want children, after the surgery, I put in an intrauterine Foley catheter. Sometimes we can fill it up. It depends on how much goes in, anywhere from 10 to 30 cc's of sterile water. They stay on that. They have oral estrogen for a month. Usually, it's esterase, 1 milligram twice a day. I see them 14 days, 16 days after surgery, but they deflate their catheter two days before. Then I'm looking inside the uterine cavity.

What am I looking for? I want to make sure these walls are not agglutinated or stuck. You will always see an eschar but you know that you don't see the fibroids anymore. Then I let them finish the total of 30 days. It's not healed at that point. The intrauterine Foley is out. They then take a full 30 days of their estrogen. Then after all the estrogen is gone, in fact, I only send them home with esterase, 1 milligram BID. I send 60 tablets. I will see them in two weeks.

Then I say to them, "Okay, it looks like it's healing well." You can still see the eschar. At day, when that bottle is empty, then it's just Aygestin for 14 days by mouth. You were to take this every day, even if you start bleeding. Don't call me. I don't want all these calls. Just take your pills. Then when you finish your Aygestin, you will normally have a withdrawal bleed within 2 to 14 days. Then that's now at about four weeks, five weeks after surgery, and I look again. By then, in my own experience, the endometrium is healed. You don't see the eschar almost, you don't see Asherman's scar tissue. That's how I handle it.

[Dr. Mark Hoffman]
You look twice. Myomectomy, intrauterine Foley catheter, 10 to 30 cc's?

[Dr. Linda Bradley]
Yes. Whatever the uterus fills up with, okay.