Trends in Hysteroscopic Endometrial Sampling in Women 70 Years and Older

Background: Women 70 years of age or older with suspected endometrial pathologies would especially benefit from office hysteroscopy due to the risks of anesthesia and high rates of clinically significant findings in this age group. However, performing office hysteroscopy in those older patients can be technically challenging, and patient cooperation, which is essential for the success of the office procedure, may be compromised in this age group. The objective of the present study was to characterize the clinical and procedural features of office and operating-room hysteroscopy in women 70 years of age or older.Methods: This was a retrospective chart analysis of all women aged 70 years and older who underwent a hysteroscopy procedure in a single tertiary-care medical center between March 2011 and August 2018. We compared the clinical and procedural characteristics of patients who underwent hysteroscopy in our outpatient clinic to those who underwent hysteroscopy under anesthesia in the operating room. Primary outcomes included procedure success and histopathological findings. Secondary outcomes included short-term complications of the procedure. Results: The data of 577 patients were analyzed. The median age at the time of the procedure was 76 years. 225 office hysteroscopy procedures and 405 operating room procedures were included. Of the 236 patients with postmenopausal bleeding (PMB), 73 (30.9%) were diagnosed with having malignancy compared to 25/341 (7.3%) patients with no PMB (p < .001, odds ratio (OR) = 5.66; confidence interval (CI) 3.46-9.26). The office procedure was successful in 194 (87%) patients. Fifty-three patients required a second hysteroscopy, which revealed 12 cases of premalignant or malignant lesions. The volume of procedures in the office increased 16 times during the study period, and the diagnostic yield of new abnormal findings by means of the procedure in the office setting has increased over time. Operating room hysteroscopy had a higher rate of complications compared to office hysteroscopy, including mortalities related to the procedure.Conclusions: Office hysteroscopy for women over the age of 70 is safe, feasible, and reliable for diagnosis of endometrial malignancy. Failed hysteroscopy and a moderate-to-high index of suspicion for malignancy indicates the need for a repeat hysteroscopy.

O-025 Value of hysteroscopy

text The 3 main characters in any ART are the uterus, the endometrium, and the embryo. With the rutinary use of 2D US and especially 3D US in infertile patients we are able to assess most of the uterine anomalies and intrauterine pathologies. Until recently, the assessment of the endometrial cavity with hysteroscopy was reserved only for cases of IVF failure, as a complementary evaluation to ensure that nothing was missed during the ultrasound scan. We also need to remember how hysteroscopy was performed in the past and, unfortunately, in some cases even today. In the old days, to assess the endometrial cavity, it was required to take the patient to the operating room and under general anesthesia, dilate the cervix to then introduce a large diameter hysteroscope only for diagnostic purposes. The prevalent working model in ART today is in close collaboration between Fertility specialists, Ultrasound and Hysteroscopy units in order to improve patient’s outcome. In our center, a diagnostic hysteroscopy is performed as part of the diagnostic workup of the infertility patient. It is performed in office setting and without anesthesia, by the staff of the reproduction and infertility unit. When we look at hysteroscopy as an in-office procedure and no longer as a procedure performed in operating room, we appreciate that it is something that all infertility patients can benefit from. The right question to ask now would be “Is there a benefit in performing a hysteroscopy to all our patients?”. Ultrasound is not perfect, especially when evaluating the endometrium. The gold standard and the only modality that we have to assess the endometrium with direct visualization is hysteroscopy. Chronic endometritis, adhesions and adenomyosis are only a few examples of what can be assessed by direct vision of the endometrial cavity. The advantages of a simple, inexpensive, office procedure such as hysteroscopy outweigh any other consideration against it. During my talk all these points will be presented helping to understand why hysteroscopy is becoming an indispensable tool in every assisted fertility unit.

Punch Incision with Secondary Healing (PISH) Technique for Benign Facial Lesions: An Institutional Experience in 307 Patients

Background Multiple or solitary facial lesions pose a unique challenge to the attending surgeon in terms of delivering the best cosmetic outcome. There are various methods in dealing with them and the preference of using them is based on the surgeon’s experience, patient expectations, and availability of instruments. One such tool, skin-punch, primarily designed for a biopsy can play a very important therapeutic role in this era of keyhole surgery. In this paper, we assess the technique of punch incision with its combination of secondary healing for various facial lesion. Methods This observational study, a total of 307 patients with solitary or multiple benign facial lesions were treated with punch incision technique using 2 to 6 mm sterile, disposable skin biopsy punches. Subsequently, the wounds were managed with healing with secondary intention. Results In our series all superficial wounds epithelized by 7 to 14 days while the deeper lesions epithelized by 14 to 28 days. We had three recurrences which were managed by fusiform excision and one patient had surgical site infection which was managed conservatively. On application of our self-devised facial scar scoring system (SCAR or Scar Cosmesis Assessment and Rating)3 on all the scars, the mean score was 6 at 1 year followup. Conclusion Punch incision with healing by secondary intention is a relatively easy, effective, single-stage office procedure. This method can be considered as an alternative method for the removal of various skin lesions, especially on face, thus providing a simple solution to complex problems.

Nicolau Syndrome Following Intralesional Sclerotherapy: A Dreaded Complication of a Simple Office Procedure

Introduction: Nicolau syndrome is an iatrogenic dreaded adverse skin reaction leading to ischemic necrosis of skin and underlying tissue after parenteral drug injection. The etiopathogenesis is poorly understood. However, inflammation, reflex vasospasm, and thrombo-embolic occlusion of blood vessels, including arterioles and arteries, are suggested as the cause of ischemia. Case Presentation: We report a 12-year-old girl who developed Nicolau syndrome after a simple office procedure of intralesional sclera therapy with sodium tetradecyl sulfate for a apyogenic granuloma on her right index finger. Three days later, she reported complaints of excruciatingly painful swelling with bluish discoloration of the right hand involving the palm, entire index, middle, and ring fingers, and distal part of the little finger. Nicolau syndrome was documented after intramuscular injections of drugs. Nevertheless, there are very few reports of Nicolau syndrome following post intralesional sclerotherapy. Conclusions: Sclerotherapy is a simple office procedure routinely performed by health care professionals (e.g., dermatologists and surgeons), and awareness about its dreaded entity is key. Stringent precautions and prompt management can prevent unfavorable complications. Additionally, prudent patient selection and detailed counseling with explicit informed consent regarding Nicolau syndrome are imperative while planning any parenteral drug injection or intralesional sclerotherapy to avoid litigation.

Ministererlaubnis und subjektiver Drittschutz

Third party protection against a ministerial permission is alive. This thesis essentially addresses the question of whether third parties can invoke subjective rights to challenge a ministerial permission within the admissibility of an action. Contrary to the prevailing view and the (presumed) intention of the legislator, it substantiates the existence of subjective rights and thereby distinguishes the "original" third party protection arising solely in the ministerial procedure from the "derivative" third party protection arising in the Federal Cartel Office procedure and continuing to have effect in the ministerial procedure. Finally, it qualitatively and quantitatively sharpens the scope of protection of subjective third party protection.

BEYOND IMAGINATION: INTEGRATED IMAGING APPROACH TO PELVIC FLOOR DISORDERS

Pelvic floor disorders (PFD) represents a significant social and economic problem involving about 25% of women older than 60 years with a 13% lifetime risk of undergoing surgery for PFD. Optimal management is impossible without comprehensive assessment of pelvic floor and multimodal approach. A combination of ultrasonic methods has several advantages (low cost, wide accessibility and availability, office procedure performed by clinicians, intraoperative technique, relatively time consuming, good compliance) and should be performed as first-line assessment in PFD.

Laser Partial Arytenoidectomy as an Office Procedure

Bilateral vocal fold paralysis is a disabling condition that results in airway symptoms, dysphonia, and sometimes difficulty swallowing. Various types of glottal widening procedures have been described in the literature, all of which are performed in the operating room under general anesthesia. The aim is to report laser partial arytenoidectomy as an office-based treatment modality in a patient with bilateral vocal fold paralysis. Using Thulium laser fiber introduced through the working channel of fiberoptic nasopharyngoscope, a posterior cordectomy followed by resection of the vocal process of the right arytenoid was performed. The laser was used in a pulsed mode, power range 3.5 to 4.5 W, duration 70 to 300 milliseconds, repetition 2 to 4 Hz, and aiming beam 65%. The procedure was well tolerated and the patient was successfully decannulated 3 weeks later. Unsedated office-based laser arytenoidectomy might be considered a safe alternative to the commonly practiced glottal widening procedures in patients with a preexisting tracheotomy.