I.V. Klyucharov A.A. Khasanov I.R. Galimova R.F. Gaifullin Journal "Practical Medicine" No. 4 (89) 2015 / Volume 1 Modern Technologies of Intrauterine Surgery: Prospects for Inpatient and Outpatient Care The article presents an overview of modern technologies for treating intrauterine pathology and recommendations for their selection in clinical practice. Some technical parameters of the instruments and indications for use are compared, attention is paid to possible complications and promising areas in the treatment of intrauterine pathology are considered. Key words: office hysteroscopy, outpatient hysteroscopy, hysteroresection, global endometrial ablation, intrauterine morcellator, shaver, complications. Over the past two decades, intrauterine surgery has undergone a large number of refinements, improvements and innovations both in diagnostics and clarification of indications, and in surgical technique and instrumentation. New technologies, which have replaced outdated ones, have transferred some procedures from the hospital to the outpatient clinic, making them safer, more effective, and more comfortable for patients. While previously the object of intervention was a formation in the uterine cavity, today some operations are possible during pregnancy. Today, intrauterine surgery is represented by office and inpatient hysteroscopy, hysteroresectoscopy, intrauterine morcellation, intrauterine thermal exposure (cryotherapy, thermal ablation, microwave ablation), and fetal surgery (Table 1). [ /upload/medialibrary/953/1.jpg ] Since the first publication of the operation by D.C. Pantaleoni in 1869, hysteroscopy has been improved until 1997 in the direction of the choice of a medium for expanding the uterine cavity, the optical system and miniaturization of the hysteroscope design, as well as the formation of a set of instruments and possible energy sources. The standard design of a hysteroscope includes the following elements: an optical tube, an outer sheath, and an intermediate sheath with channels for supplying/removing the expanding medium, as well as channel(s) for instruments or energy conductors [1-3]. In 1997, doctors S. Betocchi and L. Selvaggi presented a method of accessing the uterine cavity, later called Betocchi hysteroscopy (non-contact hysteroscopy, office hysteroscopy, or no-touch hysteroscopy) [4]. This invention made it possible to perform not only diagnostic but also surgical hysteroscopy in an outpatient setting without anesthesia. In this form, three main modifications of hysteroscopy: office hysteroscopy, inpatient hysteroscopy, and hysteroresectoscopy, still exist, competing for similar indications but with different therapeutic and surgical capabilities. It is important to note that Professor S. Betocchi substantiated the possibility of performing hysteroscopy using his method by the fact that the minimum diameter of the external and internal openings of the cervical canal, approximately 5 mm, corresponded to the external size of the hysteroscope used. We used this size as a criterion for dividing hysteroscopy into stationary and office (Table 1). By its design, an office hysteroscope is a miniaturized stationary hysteroscope and, with virtually identical therapeutic capabilities, does not require anesthesia. Thus, stationary hysteroscopy is inferior to office hysteroscopy at least in the need for anesthesia, and resectoscopy is inferior in the power of surgical action on the pathological object in the uterine cavity; accordingly, there is no need to use a hysteroscope with a diameter greater than 5 mm. Currently, resectoscopy is considered the "gold standard" for the treatment of intrauterine pathology [2, 5-7]. This technology is the most widespread. The list of indications for resectoscopy is the most complete compared to all intrauterine surgical technologies (Table 2). [ /upload/medialibrary/6b8/2.jpg ] Indications for hysteroscopy and hysteroresectoscopy include [2, 5, 7]: 1. Menstrual disorders. Diagnostic hysteroscopy has a sensitivity of 0.84-0.97 and a specificity of 0.88-0.93 in relation to the diagnosis of intrauterine pathology [8]. The possibility of simultaneous removal of the pathological formation determines the high efficiency of this procedure. 2. Impaired fertility. A significant proportion of pathology in the uterine cavity detected during hysteroscopy affects the success of infertility treatment [9]. 3. Falloposcopy. For falloposcopy (examination of the condition of the fallopian tube and some manipulations in it), a flexible hysteroscope with a diameter of 0.5 mm and a length of 150 cm is used [10]. 4. Catheterization of the fallopian tubes. This is a separate indication for tubal occlusion established by hysterofalloposcopy. For catheterization, a flexible or rigid endoscope of minimal diameter with an operating channel through which a guidewire is passed to the orifice of the tube is used. 5. Internal endometriosis (adenomyosis). Previously, it was believed that for the diagnosis of adenomyosis, endometrioid tracts, from which blood may come, should be visible during hysteroscopy on the 6th-7th day of the menstrual cycle. Today, more characteristic criteria include changes in the internal relief of the uterine cavity, the presence of scars, crypts, and an uneven rocky pattern that does not change after removal of the functional layer of the endometrium. The diagnosis is established based on a myometrial biopsy followed by morphological examination. 6. Submucous myoma of the uterine body. In hysteroscopy, the generally accepted classification distinguishes three types of nodes: type 0 - the node is completely located in the uterine cavity; Type 1 — a large (?50%) part of the node is located in the uterine cavity; type 2 — a smaller part (?50%) is located in the cavity, and the majority is located in the thickness of the uterine wall. If types 0 and 1 of myoma are an indication for hysteroresection, then type 2 requires taking into account concomitant factors. 7. Intrauterine septum. Hysteroscopy is the main method of diagnosis and treatment of septum in the uterine cavity. Hysteroscopic metroplasty reduces the incidence of miscarriage from 80 to 14%, premature birth from 9 to 6%. 8. Adhesions in the uterine cavity. The cause of adhesions is damage to the endometrium to the basal layer during curettage of the uterine cavity, as a result of endometritis, hysteroresection of several myomas, endometrial ablation, irradiation of the pelvic organs. This results in menstrual and reproductive dysfunction and various pregnancy abnormalities: habitual miscarriage, placental abruption, and intrauterine growth retardation. Office hysteroscopy and simultaneous adhesiolysis are the best treatment [11]. 9. Endometrial hyperplasia, polyps, and cancer. Adenomatous proliferative processes are clearly detected by hysteroscopy. A continuous irrigation system and the possibility of targeted endometrial biopsy allow for washing out the uterine cavity in the presence of bloody discharge and contamination, determining the extent of the process, and confirming/excluding the tumor nature of the formation. 10. Hysteroscopic fetoscopy. The examination is performed after unexpected fetal death to assess the condition of the tissues before evacuation [12]. 11. Removal of foreign bodies from the uterine cavity. Foreign bodies are represented by intrauterine contraceptives, non-absorbable surgical sutures, polymer conductors that lie freely in the cavity or are embedded in the myometrium. 12. Remnants of the fertilized egg are usually represented by fragments of the chorion, bone fragments and polyps. 13. Perforation of the uterus. It is easily detected with a significant perforation hole size, and difficult with small ones. It is optimal to use an office hysteroscope, since its small diameter allows not only to diagnose the presence, but also to safely examine the course of the perforation channel, penetration into the abdominal cavity, and determine the presence of injuries to adjacent organs and tissues. The list of possible complications is also extensive (Table 3). The introduction of bipolar energy, electrolyte media for expansion of the uterine cavity and the improvement of the design of hysteropumps, equipping them with a function for monitoring the flow rate and deficit of the expended fluid allowed to significantly reduce the number of complications and increase the safety of resectoscopy [13]. The introduction of bipolar energy has made it possible to use 0.9% NaCl to distend the uterine cavity, allowing for longer periods of time in the uterine cavity, while reducing the risk of metabolic and hemodynamic disturbances. According to M. Vleugels [14], the bipolar generator is ideal for intrauterine surgery. Recent improvements include a system for automatically removing pieces cut off by the resectoscope, and a hystero pump equipped with two roller pumps that automatically maintains preset parameters in the uterine cavity. These surgeries require general or regional anesthesia, as well as standard preoperative examination and postoperative monitoring. Resectoscopy requires extensive training and experience, a thorough understanding of the principles of electrosurgery, proficiency in surgical techniques, knowledge of the symptoms and pathogenesis of complications, and an algorithm for preventing and treating them [2, 5, 7]. [ /upload/medialibrary/544/3.jpg ] When planning surgical interventions, it is necessary to take into account the degree of complexity of the operation being performed in accordance with the following recommendations [5]: 1. targeted biopsy, division of thin adhesions, polypectomy, removal of the IUD, tubal catheterization; 2. division of third-degree adhesions, removal of large polyps and myomatous nodes up to 2 cm in diameter, and a thin intrauterine septum; 3. removal of a submucous myoma up to 5 cm in diameter or a type 2 submucous myomatous node using a resectoscope, division of adhesions in the presence of severe cicatricial adhesive process, and dissection of a thick intrauterine septum. According to V.I. Kulakov and L.V. According to Adamyan, 1st-level hysteroscopy can be performed if the clinic has a specially equipped hysteroscopy room; 2nd-level hysteroscopy can be performed if the outpatient clinic has an operating room equipped for it; and 3rd-level hysteroscopy can be performed if the hospital has a laparoscopically assisted inpatient facility [5]. Traditionally, outpatient hysteroscopy was performed only for diagnostic purposes, preparing patients for subsequent treatment in the inpatient gynecology department. In the past, the limitation of performing intrauterine procedures in the outpatient setting was the need to use larger-diameter hysteroscopes and, consequently, the need for anesthesia. With the reduction in the outer diameter of the hysteroscope, and currently modern hysteroscopes with an instrument channel having a diameter of less than 5 mm, it became possible to perform diagnostic and, subsequently, surgical procedures without anesthesia. The capabilities of modern office hysteroscopy allow: 1) to combine the diagnostic and surgical stages in a single procedure — the "See and Treat" concept; 2) to use microinstruments — mechanical, electrical, and energy conductors; 3) as a result, to ensure minimal trauma and no need for anesthesia. Scope: diagnosis of a wide range of intrauterine pathologies and their surgical treatment. Interestingly, despite such a wide range of diagnostic and therapeutic options, the available scientific and professional literature does not indicate any serious complications of office hysteroscopy. Nevertheless, none of the intrauterine surgical technologies exclude complications. The complication rate for diagnostic hysteroscopy is extremely low, amounting to 0.012%, while for operative hysteroscopy and hysteroresection it is significantly higher and is represented by more severe forms (Table 3). The presence of specific, sometimes severe and fatal, complications necessitates the improvement of technologies used in hysteroscopy. This is one of the main factors that has led to the profound improvement of old technologies and the creation of new ones: shaver technology – intrauterine morcellation, as well as 2nd generation global endometrial ablation (GAE) technologies. The intrauterine morcellator was created based on existing shaver technology, which came to us from otolaryngology. It is based on the design of a rotating knife inserted through the instrument channel of a surgical hysteroscope. The first commercial shaver samples were presented in late 2006. Currently, two types of shavers are available: with a rotary (rotating attachment) and a reciprocating cylindrical knife. Shavers can be used for submucosal fibroids, endometrial resection, resection of the intrauterine septum, and polypectomy [7]. One of the experimental prototypes was created and tested in Kazan. The results of this testing were presented in the report and materials of the XX Congress of the European Association of Gynecological Endoscopists in London in 2011 [15]. Compared with traditional surgical hysteroscopy and hysteroresection, the shaver has the following advantages: there is no excessive intravasation of fluid during surgery, hyperhyperglycemia, since There is no need to use 5% glucose as a dilating medium (often used in Russia for monopolar intrauterine surgery), perforation due to improper application of electrical energy and burns under the passive electrode due to uncontrolled current leakage (monopolar) are practically excluded, and there is no: limitation of the field of view due to contamination with chips during the operation, damage to the cervix and perforation due to repeated insertion and removal of the instrument to remove resected pieces, the need for lengthy training and gaining your own experience (as when mastering surgical hysteroscopy - hysteroresection). The disadvantages of the shaver include the need for: special equipment, a certain skill in working with a hysteroscope, anesthesia and, as a result, the possibility of complications associated with it, dilation of the cervix to No. 9 r. Hegar (the latest models require less dilation). Global ablation of the endometrium (GAE) [7]. Currently, there are 2 generations of GAE technologies. First-generation ablation/resection is performed using a ball- or loop-type electrode during resectoscopy. This procedure typically requires general or regional analgesia and anesthesia and is performed in a hospital setting. Potential complications are the same as those for hysteroresection. Second-generation hysterectomy (HEA) is represented by technologies with an improved safety profile and is recommended for outpatient use: 1) Cryoablation (Her Option cryoablation) - consists of a control unit and a 5.5 mm diameter guidewire, which is inserted into the uterine cavity. Two freezing stages are then performed (to -90 to -120?C): the first "half" of the uterine cavity is frozen for 4 minutes, followed by the second half of the uterine cavity for 6 minutes. 2) Microwave ablation (Microsulis microwave ablation) — consists of a control unit and a disposable/reusable uterine guidewire with a 2.3 GHz emitter at the end, which heats the uterine tissue to 75-80?C. The length of the uterine cavity is predetermined, the guidewire is inserted until it touches the fundus, and sequential ablation of the fundus and walls of the uterus is performed. The procedure lasts approximately 4-5 minutes. 3) Balloon thermal ablation (TermaChoice, Cavaterm) — consists of a 5.5 mm diameter guidewire with a silicone balloon and a heating element at the end. After insertion into the uterine cavity, the balloon is inflated and heated to 80-87?C with a solution for 8-15 minutes. 4) Another thermal ablation system (Hydro ThermAblator (HTA) System) consists of a control unit and a disposable plastic 8 mm diameter tube for a standard hysteroscope with a fluid supply and drainage system. After the diagnostic hysteroscopic stage, the fluid used for hysteroscopy is heated to 90?C and circulated in the uterine cavity for 10 minutes. The procedure is completed with a control hysteroscopy. 5) Radiowave (electro-) ablation (Novasure system) consists of a control unit - a high-frequency electro-generator and a 7.2 mm diameter 3D uterine guidewire, at the end of which is a bipolar emitter. A distinctive feature of the procedure is the use of aspiration, which ensures contact of the emitter with the uterine surface and the removal of coagulation products. The duration of the procedure is 90 seconds. Достоинствами этих систем являются: незначительная длительность процедуры (от 1,5 до 15 минут), одномоментное проведение аблации, возможность проведения процедуры под местной анестезией, т.е. в условиях амбулатории, хороший уровень переносимости, высокая (сравнимая и превышающая 1-е поколение) эффективность лечения маточных кровотечений. Условиями для проведения ГАЭ 2-го поколения являются: предварительная гистероскопия, длина матки по зонду 4-12 см, отсутствие органической внутриматочной патологии (миома тела матки, полипы эндометрия, синехии, внутриматочная перегородка, инородные тела), предоперационная/интраоперационная подготовка с целью уменьшения толщины эндометрия. Ограничивающие факторы: наличие органической внутриматочной патологии, большие размеры полости матки, несостоятельность миометрия (рубец после операций на матке). Возможные осложнения процедуры описаны Gurtcheff S.E. et al. [16]: послеоперационная боль и лихорадка (у большинства пациентов проходит в течение 8 часов после операции), гематометра и пиометра, постстерилизационный синдром, эндометрит, абсцесс трубы, некроз миомы, стеноз цервикального канала. Тяжелые осложнения редки и представлены: ожогами внутренних органов, и прилежащих тканей, перфорациями матки, потребовавшими лапаротомии, расширения объема вмешательства, и приведшие в единичных случаях к гибели пациенток. По мнению Савельевой Г.М. и соавт. [7], обобщенная эффективность ГАЭ 1-го и 2-го поколения сравнима, составляет от 76 до 87%, с уровнем осложнений от 0,04 до 6,4% и вероятностью гистерэктомии от 3 до 21%. Заключение На пороге ХХI века началось зарождение и развитие новой отрасли оперативной гинекологии — внутриматочной хирургии. Многочисленные инновации повысили безопасность и эффективность гистероскопических технологий и позволили расширить границы их применения как в стационарных, так и амбулаторных условиях. Сегодня происходит эволюционное вытеснение старых технологий новыми. Так, монополярная резектоскопия практически вытеснена биполярной резектоскопией, а гистероскопия по Бетокки должна вытеснить стационарную гистероскопию в обозримом времени. В стационаре шейверная технология успешно конкурирует с гистерорезекций, и на помощь последней пришли системы с автоматическим извлечением удаленных кусочков. Вероятно, ГАЭ 2-го поколения станут преимущественной технологией лечения ряда аномальных маточных кровотечений и «заберут» часть пациентов у гистерорезекции /аблации эндометрия. Разнообразие технологий и инструментов, имеющих совпадающие показания к применению, однако различающихся по эффективности, безопасности и удобству применения позволяют нам сделать выбор, наиболее отвечающий запросам пациентки. Однако отдельные вопросы применения технологий внутриматочной хирургии требуют дальнейшего исследования и осмысления. ЛИТЕРАТУРА 1. Rafael F. Valle Development of hysteroscopy: From a dream to a reality, and its linkage to the present and future // Journal of Minimally Invasive Gynecology. — 2007. — Vol. 14(1). — P. 407-418. 2. Стрижаков А.Н., Давыдов А.И. Гистерорезектоскопия. — М.: Медицина, 1997. — 180 с. 3. Кливленд Г.О., Абросимова М.Ю., Ключаров И.В. и др. Краткий очерк о вкладе в развитие гистероскопии отечественных гинекологов и гинекологов г. Казани // Журнал международной медицины. — 2014. — №5 (10). — C. 35-37. 4. Betocchi S., Selvaggi L. А vaginoscopic approach to reduce pelvic pain of office hysteroscopy // J Am Assoc Gynecol Laparosc. — 1997. — Vol. 4. — P. 255-258. 5. Кулаков. В.И., Адамян Л.В.. Эндоскопия в гинекологии: руководство для врачей. — М.: Медицина, 2000. — C. 180-190. 6. Ключаров И.В., Кливленд Г.О. Гистероскопия и биполярная энергия // Журнал международной медицины. — 2014. — №5 (10). — C. 88-90. 7. Савельева Г.М., Бреусенко В.Г., Каппушева Л.М. Гистероскопия: атлас и руководство. — М.: ГЭОТАР-Медиа, 2013. — 248 с. 8. Daniilidis А., Pantelis А., Dinas K. et al. Indications of diagnostic hysteroscopy, a brief review of the literature // Gynecol Surg. - 2012. - Vol. 9. — P. 23-32. 9. Fernandez H., Gervaise A., de Tayrac R. Operative hysteroscopy for infertility using normal saline solution and a coaxial bipolar electrode: a pilot study // Hum Reprod. - 2000. - Vol. 15. — P. 1773-1775. 10. Sharma A., Bhalla R., O’Donovan P. Endoscopic procedures in ART: an overview // Gynecol Surg. - 2004. - Vol. 1. — Р. 3-9. 11. Тарасенко Ю.Н., Салов И.А., Ташухожаева Д.Т. и др. Внутриматочные синехии: современный взгляд на проблему // Современные проблемы науки и образования. — 2013. — №4. — C. 141-145. 12. Депрест Ян. Обзор достижений в лечении внутриутробной патологии плода // Проблемы репродукции. — 2009. — №4. — С. 62-74. 13. Kumar A., Kumar A. New hysteroscopy pump to monitor real-time rate of fluid intravasation // Journal of minimally invasive gynecology. — 2012. — Vol. 19(3). — Р. 369-375. 14. Vleugels MPH Normal saline field bipolar electrosurgery in hysteroscopy: report of the first 163 cases // Gynaecol Endosc. - 2001. - Vol. 10. — Р. 349-353. 15. Klyucharov I., Hassanov A., Samigullova A. A shaver-like system (SLS) for intrauterine pathology treatment, preclinical investigation // Gynecological surgery. - 2011. - Vol. 8(Suppl. 1). — Р. 207. 16. Gurtcheff S.E., Sharp M.T. Complications associated with global endometrial ablation: the utility of the MAUDE database // Obstet Gynecol. — 2003. — 102. — Р. 1278-1282