I.V. Klyucharov A.V. Shulaev R.F. Gaifullin R.R. Timershin On the development of hysteroscopic technologies Journal "Practical Medicine" No. 4 (96) August 2016 / Volume 2 Using a questionnaire, the availability of hysteroscopic equipment, staffing and the effectiveness of using hysteroscopy in healthcare institutions of the Republic of Tatarstan were assessed. Key words: diagnostics, hysteroscopy, availability of equipment, staffing, questionnaire. Since the first brief publication by P. Bozzini in 1804 about an instrument for examining body cavities and up to the present day, hysteroscopy has undergone a significant evolutionary path of development and has become the most effective method for diagnosing and treating pathological conditions associated with the uterine cavity [1]. Due to its high diagnostic accuracy (sensitivity and specificity approaching 100) and exceptional possibilities for therapeutic and surgical application, hysteroscopic technologies successfully compete with therapeutic (contraception) and surgical (curettage of the uterine cavity, removal of the uterus) interventions [2]. The Order of the Ministry of Health of the Russian Federation of November 1, 2012, No. 572 (with amendments and additions) [3] regulates the performance of hysteroscopy in a women's health clinic, as part of the organization of a surgical room, in a hospital as part of the work of the obstetric and gynecological departments and as part of the center for the protection of family health and reproduction at the stages of diagnosis and treatment of: postpartum hemorrhage, ectopic pregnancy, placental polyp, complications of termination of pregnancy, infertility, benign diseases of the cervix, uterine leiomyoma, adenomyosis, ovarian endometriosis, congenital anomalies of the genitals, endometrial hyperplasia, menstrual irregularities and bleeding, dysmenorrhea, fistulas involving the female genital organs. INNOVATIVE TECHNOLOGIES IN MEDICINE / VOLUME 2 In the Republic of Tatarstan (hereinafter RT), there were 155 health care institutions (hereinafter LPI) providing obstetric and gynecological care to the population as of 2012. Of these, 104 were antenatal clinics and 51 were inpatient facilities, which had 1,526 gynecological beds. Obstetric and gynecological care was provided to 2,055,137 women living in the territory of the Republic of Tatarstan by 942 obstetricians and gynecologists. Of the 2,055,137 women, 973,983 were of childbearing age, being the main consumers of medical services related to the reproductive system (Fig. 1). Having reviewed the available scientific and practical literature, we found that the number of publications on the scale of the effectiveness of hysteroscopy in the Russian Federation and the Republic of Tatarstan is extremely limited. The aim of the study was to assess the availability of hysteroscopic equipment, staffing with personnel authorized to provide this type of service, and the effectiveness of hysteroscopy in healthcare facilities of the Republic of Tatarstan. To achieve this goal, a special questionnaire was developed and distributed to the relevant medical organizations of the Republic of Tatarstan via e-mail. The questionnaire was created in Microsoft Excel and consisted of questions addressed to the management of the institution in the form of a structured table printed on A4 sheets. The questionnaire contained 120 questions regarding: 1. Employees of the gynecology department; 2. The number of patients treated in the institution due to a pathology that involves the use of hysteroscopy at the diagnostic and/or surgical stage; 3. Research methods used in this institution to diagnose the above-mentioned pathology; 4. Number of gynecological beds in the hospital; 5. Availability of equipment for hysteroscopy and some of its characteristics; 6. Number of hysteroscopy procedures performed in the institution in 2012; 7. Number of patients who, due to the diagnosis of DUB, underwent: • organ-preserving surgeries; • organ-removing surgeries; 8. Number of patients who, due to the diagnosis of submucosal and interstitial uterine fibroids, underwent: • organ-removing surgeries; • organ-preserving surgeries; 9. Number of complications typical for hysteroscopy; 10. Additional questions for antenatal clinics. Research Results A total of 36 healthcare institutions (23%), employing 270 (29%) specialists, participated in the survey. Of the 270 gynecologists, 23 were certified in endoscopy, 20 were certified in hysteroscopy, and 15 had completed office hysteroscopy training (on-the-job training, without certification). On average, there was 1 certified specialist per 2 institutions: 0.6 specialists were certified in endoscopy, 0.5 specialists were certified in hysteroscopy, and 0.4 specialists had completed short-term training in office hysteroscopy. Of the 37 physicians performing hysteroscopy, there was an average of 1.0 specialist per institution. Thus, the presence of at least one trained specialist facilitates the use of a hysteroscope in clinical practice. However, it should be noted that only about half of the physicians were certified to perform the relevant activities. The survey revealed that 36 institutions had 27 hysteroscopes, i.e., On average, 0.8 hysteroscopes were used per healthcare facility. Of these, 12 hysteroscopes (0.3 per facility) were standard models with a 4.0 mm diameter optic and an external diameter greater than 5 mm, requiring hospitalization and anesthesia. Eleven hysteroscopes (0.30 per facility) were modern small-diameter models with a continuous irrigation system and an instrument channel. Three resectoscopes required operating room conditions (0.08 per clinic). [ /upload/medialibrary/d16/ris_1.jpg ] [ /upload/medialibrary/d16/ris_1.jpg ] Fig. 1. Age and sex composition of the population of the Republic of Tatarstan, according to the 2010 census Updated data show that 5 healthcare institutions had 2 hysteroscopes each, 17 had 1 hysteroscope each, and 14 of the institutions participating in the survey did not have a hysteroscope. For comparison, on average in the UK there are 2-3 modern small-diameter hysteroscopes that can be sterilized by autoclaving per gynecology department. This number of autoclavable hysteroscopes allows to avoid delays when performing several hysterscopies per day, and ensures significantly greater efficiency of the department. When analyzing the frequency of instrument use, it was found that in 2012 a total of 1,225 hysterscopies were performed, i.e. 34 hysteroscopies are performed per institution per year, with an average of 2.5 hysteroscopies per month per physician. This situation hinders the efficient use of equipment within the institution, and the low number of procedures prevents physicians from quickly gaining practical experience. By comparison, a single gynecology department in the UK might perform 3-4 procedures per day, or 15-20 procedures per week. [ /upload/medialibrary/99d/ris_2.jpg ] [ /upload/medialibrary/99d/ris_2.jpg ] Fig. 2. Distribution of indications for diagnostic hysteroscopy. On average, 1 institution performed: DUB — ??46.1 cases, uterine fibroids — 33.4 cases, endometrial hyperplasia — 31.9 cases, endometrial polyps — 24.5 cases, pelvic pain — 19 cases, developmental anomalies — 0.5 cases, uterine adhesions — 0.4% of cases, virgo — 2 cases. Of the 1,225 hysteroscopic operations, 744 were performed for diagnostic purposes. The main indications for diagnostic hysteroscopy were: endometrial hyperplastic lesions (29%), endometrial polyps (26%), uterine bleeding (26%), and uterine fibroids (12%). Less common indications included pelvic pain syndrome (4%), infertility and miscarriage (2%), and uterine adhesions (1%) (Fig. 2). Interestingly, postmenopausal diagnosis, changes detected during examination of the uterus and tubes, suspected endometrial tumor, developmental anomalies and a foreign body within the uterine cavity, amenorrhea, and the "virgo" state were not indications for hysteroscopy among the institutions surveyed in 2012. However, for 74 "virgo" states, two uterine curettage procedures were performed, which are characterized as a less accurate and more traumatic diagnostic method. A preliminary diagnosis of uterine cavity pathology was established in the overwhelming majority of patients (59%) using ultrasound; curettage of the uterine cavity was performed in 28% of cases, and hysteroscopy was performed in 10%. Ultrasound hysterosalpingography (2%) and X-ray hysterosalpingography (1%) were performed extremely rarely (Fig. 3, see table). It should be noted that out of 744 diagnostic hysteroscopies, 74 were performed on an outpatient basis, without anesthesia, and 670 were performed in a hospital, under anesthesia. Among 284 surgical hysteroscopies/resectoscopies, the following were performed: endometrial biopsy - 114, endometrial polyp resection - 85, endometrial ablation - 28, endometrial resection - 2, resection of the intrauterine septum - 1 case. [ /upload/medialibrary/6ca/ris_3.jpg ] [ /upload/medialibrary/6ca/ris_3.jpg ] Fig. 3. Distribution of the proportion of studies conducted in connection with the diagnosis of uterine cavity pathology in 2012. It is interesting to compare the number of organ-preserving and organ-bearing operations. Thus, in connection with uterine bleeding, organ-preserving operations were performed in 53 cases, and organ-bearing operations - in 34 cases. The number of patients who underwent organ-preserving myoma resection was 2 people, and 27 hysterectomies were performed. Thus (see table), in 2012, hysteroscopy in medical institutions of the Republic of Tatarstan was performed for a wide range of indications, but mainly for polyps and endometrial hyperplasia, uterine bleeding and uterine myoma. The above-mentioned indications were used in 1125 cases, which constituted 92%. Hysteroscopy, being a recognized standard for the diagnosis and treatment of uterine pathology, accounted for only 10% of cases among the technologies used for the diagnosis of uterine pathology. This was facilitated by a number of factors such as the uneven distribution of equipment among healthcare institutions and the lack of training for half of the physicians performing hysteroscopy. Considering that hysteroscopy is a technology that requires systematic implementation for mastering, the small number of procedures is a logical result of the current state of affairs. The European Society of Gynecological Endoscopy has formulated criteria for the complexity of mastering hysteroscopic procedures [4]. These recommendations contain a classification of the complexity of hysteroscopic procedures and quantitative criteria for their performance in order of increasing complexity. It should be noted that the long-term evolutionary development of technology has led to the emergence of a highly effective and safe method of contactless hysteroscopy, also called "office hysteroscopy" and "Betocchi hysteroscopy". This method allows for diagnostics and, in some cases, intrauterine interventions without anesthesia, which allows for circumventing many of the limitations of hysteroscopy. We believe that its wider implementation in outpatient settings would improve the efficiency of diagnostics and reduce the costs of other, less accurate methods for diagnosing intrauterine pathology, on the one hand, and ensure more efficient use of resectoscopes in high-level hospitals, on the other. [ /upload/medialibrary/eed/ris_4.jpg ] [ /upload/medialibrary/eed/ris_4.jpg ] Fig. 4. Intrauterine pathology and methods used in its diagnostics LITERATURE 1. Valle R.F. Development of hysteroscopy: from a dream to a reality? And its linkage to the present and future // JMIG. ? 2007. ? 14. ? P. 407-418. 2. Garuti G.1., Sambruni I., Colonnelli M., Luerti M. Accuracy of hysteroscopy in predicting histopathology of endometrium in 1500 women // J. Am. Assoc. Gynecol. Laparosc. ? 2001 May. ? 8 (2). ? P. 207-13. 3. Order of the Ministry of Health of the Russian Federation of November 1, 2012 N 572n "On approval of the Procedure for the provision of medical care in the profile of "obstetrics and gynecology (except for the use of assisted reproductive technologies)"" (with amendments and additions) GARANTEE System 4. http://www.esge.org/education/endoscopic-training/esge-hysteroscopy-standard [ http://www.esge.org/education/endoscopic-training/esge-hysteroscopy-standard ]