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11THERAPEUTIC EFFICACY OF DILATATION AND CURETTAGE IN ENDOMETRIAL POLYPS: IS IT A VALUABLE METHOD?
Afktn YILDIZ1, M. Hakan YETIMALAR1, Hayri AKSUT1, Burcu Harmandar KASApi, Derya Ktltf SAKARYAi, Ay$e Gulsun AKSUT2
'Izmir Ataturk Training and Researh Hospital, Depart. of Gynecology and Obstetric, Izmir, Turkey 2Izmir Tepecik Training and Researh Hospital, Depart. of Family Medicine, Izmir, Turkey
Rezumat
Eficacitatea terapeutica a dilatarii si chiuretajului în polipii endometriali
Studiul a fost efectuat în perioada iunie 2008 - martie 2011, la Spitalul de Educatie si Cercetare Ataturk din Izmir, Turcia. 36 de femei cu sângerare uterinü anormala, care au suferit o dilatare si chiuretaj si la care evaluarea histopatologica a diagnosticat polip endometrial, au fost incluse în studiu. Toate pacientele au suportat histeroscopie imediat dupa menstruatie. Au fost evaluate rezultatele §i ratele.
Noua (25%) dintre paciente au fost vindecate prin dilatare si chiuretaj si 27 (75%) au fost tratate cu succes prin histeroscopie. Diagnosticul a fost dovedit, polipii fiind eliminati prin histeroscopie de birou.
In caz de hemoragii uterine anormale, cum arfipolipul endometrial, histeroscopia de birou este o metoda mult mai utila decât dilatarea si chiuretajul, pentru ca este o metoda simplaprin care pacientul poate fi tratat la momentul diagnosticarii.
Cuvinte-cheie: dilatare si chiuretaj, polip endometrial, histero-scopie de birou.
Резюме
Терапевтическая эффективность расширения и кюре-тажа в эндометрических полипах: действительно ли это ценный метод?
Исследование проводилось с июня 2008 до марта 2011 года в Измир Ататюрк учебной и научной больнице, отделение гинекологии и акушерской помощи, Измир, Турция. Тридцать шесть женщин с аномальными маточными кровотечениями, которые прошли диагностическое выскабливание и у которых был поставлен диагноз полип эндометрия, были включены в исследование. Всем пациенткам проводилась амбулаторно-офисная гистероскопия сразу же после их очередной менструации. Результаты диагностического выскабливания и гистероскопии были оценены.
Девять (25%) пациенток могут быть полностью вылечены при помощи диагностического выскабливания и 27 (75%) пациенток были успешно пролечены офисной гистероскопией. Диагноз был гистологически доказан, а полипы были удалены посредством офисной гистероскопии. В случаях патологии матки, которые вызывают аномальные кровотечения, как полип эндометрия, офисная гистероскопия является более полезной, чем метод диагностического выскабливания, потому, что это простой метод, который позволяет лечить пациента на момент постановки диагноза.
Ключевые слова: дилатация и кюретаж, полип эндометрия, офисная гистероскопия.
Introduction
Dilatation and curettage (D&C) is a surgical procedure in which the cervix is dilated and a curette inserted in to the uterus to sample or remove tissue from the endometrial cavity. D&C is used to diagnose uterine disorders or treat in conditions such as abnormal uterin bleeding [1] or after miscarriage. Complications include introduction or spreading of infection, uterine perforation and adhesions.
Including dilatation and curettage, the false negativity rates of all endometrial biopsies were detected between 2-6% and in only smaller than 60% of the patients the endometrial cavity can be sampled [2]. It is concluded that D&C can be regarded as the 'golden standart' for abnormal uterine bleedings [3].
Endometrial polyps are common hyperplastic pathologic findings in gynecologic pathology practice. The majority of these lesions are benign and the malignant changes in these lesions are uncommon. Although most of them are asymptomatic and identified during routine pelvic examination or infertility evalu-tion, they are one of the main organic lesions that causes abnormal uterine bleeding.
Hysteroscopy is an endoscopic procedure usually used in anormal uterine bleeding and for removing adhesions, diagnose the cause of repeated miscarriage, locating an intra-uterin device and also for some sterilization tecniques. It allows finding out the source of the pathology and perform a biopsy of the suspected area. It is a safe procedure but complications like perforation, infection or electrolyte imbalance may occur. The importance of hysteroscopy is being aggravated in both diagnoses and treatment of intrauterine lesions by the development of noninvasive and invasive diagnostic procedures in modern gynecology [4, 5, 6]. Abnormal uterine bleeding is the leading indication for hysteroscopy [2, 7]. Office hysteroscopy which can give the possibility of both visualisation and treatment of intrauterine lesions seems to be the best
diagnostic and therapeutic choice for illuminating the etiology of abnormal uterine bleeding [2, 8]. The diagnostic efficacy of office hysteroscopy is better than D&C and it is becoming to take the place of D&C in patients with abnormal uterine bleeding [8-15]. In the study, we aimed to evaluate the therapeutic efficacy of D&C in endometrial polyps.
Material and Methods
This retrospective study was performed at Izmir Ataturk Training and Research Hospital 3rd Obstetrics and Gynecology Department from June 2008 through March 2011. One hundred twenty nine patients who applied for abnormal uterine bleeding and underwent D&C were evaluated. Thirty six (27.9%) of those 129 patients who were diagnosed as endometrial polyp were included in the study. Office hysteroscopy were carried out just after the end of menstrual bleeding period. Informed consent forms were taken from all patients before D&C and hysteroscopy procedures. All the procedures were applied by the same doctors. According to data gained by D&C and office hysteroscopy, therapeutic rates were obtained. Microsoft Office Excel 2007 program was used to evaluate data.
Hysteroscopic procedures were applied by local anesthesia or without anesthesia according to the office availability by office hysteroscope (diameter 2 mm, length 26 cm, Forward Oblique Telescope 30o, Bettochi Continuous-Flow Operating Sheath 4.2 mm, semirigid, 5 Fr., length 34 cm instruments, Storz, Germany). Uterine cavity distension was done by %0,09 NaCl or by %5 mannitol sollution when electrocautery was used. Neither vaginal speculum nor tenaculum was used during procedures. By the direct visualisation under the guideness of hysteroscope; the introitus was passed through vagina. Finally uterine portion was found and uterine cavity was reached through endocervical canal. Endocer-vical canal, uterine fundus, tubal ostiums, anterior and posterior uterine walls were examined in detail. Hysteroscopy was evaluated as efficient when bilateral ostiums, endometrial cavity and endocervical canal were all examined. Hysteroscopic view was determined as normal in cases of when adequate uterine cavity and endometrium in early proliferative phase and no structural abnormality. In addition, endometrial biopsies were taken under the view of hysteroscopy.
Results
One hundred twenty nine patients who applied for abnormal uterine bleeding underwent D&C were evaluated. Of the 36 (27.9%) 129 patients, who were diagnosed as endometrial polyp were included in the study. One hundred eight (83.72%) of 129 pati-
ents were in the period of premenapause while 21 (16.28%) were in the postmenapausal period.
The mean age of the patients was 45.09±3.06 (range from 27 to 63). 6 patients were (4.65%) were between the ages of 25-29, 3 (2.32%) were between the ages of 30-34, 18 (13.95%) were between the ages of 35-39, 36 (27.90%) were between the ages of 40-44, 39 (30.23%) were between the ages of 45-49, 9 (6.97%) were between the ages of 50-54 and 18 (13.94%) were between the ages of 55-63.
The mean duration of bleeding was 22.88 months (minimum 2 months, maximum 10 years) for premenaupausal patients and 7.7 months (minimum 1 month, maximum 2 years) for postmenapausal patients. Bleeding characteristics of the patients were menomethroragia in 84 (65.1%) patients, methroragia in 24 (18.6%) patients and postmenapausal bleeding in 21 (16.3%) patients. In 9 (25%) of 36 patients who were diagnosed as endometrial polyps by D&C, endometrial polyps were not detected by office hysteroscopy and the removal of polyps by D&C was failed in 27 (75%) patients. In these 27 patients, polyps were detected and treated by office hysteroscopy. Polyps which were removed by office hysteroscopy were also confirmed histopathologically. The distribution of patients with polyp is shown in table.
Distribution of patients with polyp
Method Polyp Normal Total
D&C 36 - 36
Hysteroscopy 27 9 36
Discussion
The importance of hysteroscopy is being adopted in both diagnosis and treatment of intrauterine lesions and abnormal uterine bleeding by technological development in modern gynecology [4, 5].
In this study, we proposed to test the therapeutic efficacy of D&C. The rate (25%) was not regarded enough to be a therapeutic method. In 2001, Gebauer et al. claimed that D&C alone was inadequate in determination and treatment of polyps. D&C could detect only 43% of polyps which were previously detected by hysteroscopy [16]. The diagnostic efficacy of D&C was argued. Leather emphasized that D&C could have got samples in less than 60% of the uterine cavity in patients with abnormal uterine bleeding while in 16% of the patients only one fourth of the cavity could have been sampled [9]. It was also reported that the rate of endometrial polyp detection was 10-25% by the D&C alone [17, 18].
Risk of uterine perforation is 0.6-1.3% and risk of bleeding is 0.4% in office hysteroscopy procedures [17, 18]. Any other complications were not seen during the procedures. In 2002, Ceci et al. reported that the sensitivity was 98%, the specificity was 95%, the positive predictive value was 96% and the negative
predictive value was 98%. They also reported that office hysteroscopy had a better diagnostic efficacy than D&C [8]. Garuti et al. reported that the sensitivity of hysteroscopy was 94%, the specificity was 88.8%, the negative predictive value was 96.3% and the positive predictive value was 83.1% in detection of endometrial polyps [19].
In 2001, Epstein et al. emphasized that hysteroscopy was superior to D&C in cases with adequate en-dometrial samples in postmenapausal patients with bleeding and suspicious lesions in endometrial cavity with endometrial thickness 5 mm or higher [20].
Gimpelson and Rappold compared the biopsy results of D&C and hysteroscopy in 276 abnormal uterine bleeding patients and reported that the results were similar in 223 patients (80.8%). In 44 (16%) patients, hysteroscopy had better results than D&C and in only 9 (3.3%) patients D&C was superior to hysteroscopy [10].
As a research procedure hysteroscopy was superior to D&C in intrauterine abnormality detection by direct visualisation of uterine cavity [10-14]. In many studies, it was concluded that the hystero-scopy was an excellent procedure for detecting intrauterine pathology and treatment at the same time [14, 18, 21, 22].
Conclusion
D&C has a controversial and restricted role in abnormal uterine bleeding evaluation due to its low diagnostic and therapeutic efficacy. Office hysteroscopy can be regarded as one of the alternatives in evaluation of abnormal uterine bleeding. It has the advantages such as availibility in office with scarce or without anesthesia, low cost, superiority to D&C in diagnosis and tolerability.
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Prezentat la 31.01.2013
