Hysteroscopy

COMPLICATIONS—Complications from hysteroscopy are rare, but some are potentially life threatening.

A multicenter study of 92 centers and over 21,000 operative hysteroscopic procedures reported a complication rate of 0.22 percent [60]. The most common complication was perforation of the uterus (0.12 percent), followed by fluid overload (0.06 percent), intraoperative hemorrhage (0.03 percent), bladder or bowel injury (0.02 percent), and endomyometritis (0.01 percent).
Another multicenter study reported data from both diagnostic and operative procedures [61]. The study involved 82 hospitals and 13,600 procedures; the overall complication rate was 0.28 percent. Diagnostic hysteroscopy had a significantly lower complication rate than operative hysteroscopy (0.13 versus 0.95 percent).

The most common complication of both types of hysteroscopy was uterine perforation (0.13 for diagnostic; 0.76 percent for operative); 18 of 33 perforations occurred during entry (measuring the size of the uterus with the sound instrument, dilation problems, perforation by hysteroscope). Fluid overload occurred in operative (0.02 percent), but not diagnostic, procedures. The operative procedure with the highest frequency of complications was intrauterine adhesiolysis (4.5 percent complication rate); all of the other procedures had complication rates less than 1 percent.

In a systematic review of over 26,000 women who underwent diagnostic hysteroscopy, complication rates were reported by only 29 percent of studies, totaling 9413 procedures [57]. Among these procedures, there were only eight complications: four uterine perforations, one pelvic infection, one bladder perforation, and two medical complications.

Uterine perforation—Uterine perforation is the most common complication of hysteroscopy. In most studies, hysteroscopy is complicated by confirmed uterine perforation in 0.8 to 1.6 percent of operative procedures [60-64]. The perforation rate is less during diagnostic hysteroscopy (eg, 0.1 versus 1.0 percent with operative hysteroscopy percent in a series of 13,600 procedures) [61].

A uterine perforation can occur during mechanical cervical dilation or insertion of the hysteroscope. Such a perforation may be recognized when an instrument passes beyond depth of the uterine fundus, when there is sudden loss of visualization, when omentum or bowel or peritoneal structures can be visualized at the uterine fundus, or when there is a sudden increase in the fluid deficit.

If a uterine perforation occurs, all instruments should be removed from the uterus and the hemodymic status of the patient should be assessed. A detailed discussion of the management of uterine perforation can be found separately. (See "Uterine perforation during gynecologic procedures".)

Urinary tract or bowel injury—Bowel or bladder injury are rare, but may occur in association with uterine perforation or as a result of use of electrical current. Management of these injuries is discussed in detail elsewhere. (See "Complications of gynecologic surgery", section on 'Urinary tract injuries'and "Complications of gynecologic surgery", section on 'bowel injury'.)

Cervical laceration—Cervical lacerations can occur, particularly in women with cervical stenosis. Lacerations that are large or are bleeding require sutures.

Excessive fluid absorption—Complications related to distending media vary according to the patient population and the media used. A complete discussion of management of distending media can be found separately. (See "Hysteroscopy: Managing fluid and gas distending media".)

Embolism—Embolism (air or carbon dioxide) can occur with any hysteroscopic technique and can cause cardiovascular collapse. A complete discussion of management of distending media and prevention of gas embolism can be found separately. (See "Hysteroscopy: Managing fluid and gas distending media".)

Hemorrhage—Potential sources of intraoperative bleeding include operative sites, uterine perforation, and cervical laceration.

Bleeding from cervical lacerations that is recognized at surgery can be controlled using electrocautery or sutures.

When postoperative bleeding occurs (and there is no suspicion of uterine perforation), it can be treated by placing a Foley catheter in the uterine cavity and then distending the bulb with 15 to 30 mL of water. In one series of 216 resectoscope procedures, four women (1.9 percent) developed postoperative uterine bleeding and were successfully treated with this procedure [65].

Electrosurgical injury—Thermal effects of electrical (or laser) energy can cause injuries to the uterine cavity, as well as bowel, urinary bladder, and large pelvic vessels [66]. In particular, a significant risk of bowel injury has been reported from hysteroscopic coagulation of the tubal cornua for sterilization [67]. One must be cautious if coagulating in the tubal recesses.

The risk of electrosurgical injury can be minimized by always moving the electrical instrument when it is activated because the temperature of the uterine serosal surface does not rise appreciably if the instrument is not held stationary during coagulation [68]. Vaginal thermal injury may result from overdilation of the cervix or activation of current when the external sheath is less than 2 cms past the external cervical os [69]. Electrode insulation defects can also cause thermal injury.

Sepsis generally results from unrecognized thermal bowel injury; fistulae or urinary ascites can occur from an unrecognized bladder injury. Such complications require consultation with a colorectal surgeon, urologist, or infectious disease specialist.

Infection—The risk of infection after operative hysteroscopy is low. Studies of 2000 or more procedures report postoperative incidences of 0.1 to 0.9 percent incidence for endometritis and 0.6 percent for urinary tract infections [60,61,70].

Dissemination of tumor—Concerns regarding the dissemination of malignant cells during hysteroscopy are discussed separately. (See "Evaluation of the endometrium for malignant or premalignant disease", section on 'Risk of tumor dissemination'.)

SUMMARY AND RECOMMENDATIONS

Hysteroscopy is a procedure in which a telescope with a camera is used to evaluate or treat pathology of the endometrial cavity, tubal ostia, or endocervical canal. (See 'Indications'above.)

Hysteroscopy in outpatient settings is increasingly common. Advances in instrumentation, including narrow caliber hysteroscopes, decrease patient discomfort and have facilitated use of local anesthetic and ambulatory procedures. (See 'Hysteroscopes'above.)

During hysteroscopy, the uterus is distended with a gas or fluid medium. Each medium has benefits and risks, including fluid overload or gas embolism. (See "Hysteroscopy: Managing fluid and gas distending media".)

On the night before hysteroscopy, we recommend the use of vaginal misoprostolin premenopausal women (Grade 1A)and suggest its use in postmenopausal women (Grade 2B)rather than no preparation. (See 'Entry and cervical dilation'above.)

Prophylactic antibiotics are not routinely administered during hysteroscopy since posthysteroscopy infection is rare. (See 'Preoperative preparation'above.)

Most diagnostic and brief or minor operative procedures can be performed without anesthetic or with a local anesthetic. Regional or general anesthesia is reserved for patients who cannot tolerate a procedure under local anesthesia, extensive operative procedures, or patients with comorbidities that necessitate intensive monitoring. (See 'Anesthesia'above.)

In women undergoing hysteroscopy under local anesthetic, we suggest a paracervical block over other methods of administering local anesthesia (Grade 2B). (See 'Anesthesia'above.)

The vaginoscopic technique for hysteroscopy avoids the use of a speculum and tenaculum. This may increase operator ease or patient discomfort in some procedures.
Hysteroscopic complications are infrequent. Major complications include: uterine perforation, fluid overload, and gas embolism.

COMPLICATIONS AND ADVERSE EFFECTS

Fluid overload—Fluid overload is rare, occurring in 0.06 to 0.2 percent of operative hysteroscopy procedures [11,12]. Complications related to distending media vary according to the patient population and the medium used.

A patient's ability to adapt to fluid overload varies with age and comorbid conditions. Absorption of large volumes of electrolyte-poor fluid may result in the following complications:

Volume overload — acute decompensated heart failure, pulmonary edema, dilutional anemia
Electrolyte or other plasma imbalance — hyponatremia, hypoosmolality, hyperammonemia, hyperglycemia, acidosis
Neurologic sequelae —slurred speech, visual disturbances, hypersomnia, confusion, seizures, coma

During hysteroscopy, absorption is increased when venous sinuses are exposed (eg, during myomectomy). In addition, minimal fluid extravasates through the Fallopian tubes; history of prior sterilization does not alter total absorption [13,14].

Hyponatremia is a particular risk with electrolyte-poor fluids. This topic is discussed in detail separately. (See "Hyponatremia following transurethral resection or hysteroscopy".)

Prevention of fluid overload—Fluid overload and electrolyte imbalance can be prevented by following several operative principles (see 'Fluid media'above:

Use isoosmolar, electrolyte fluids whenever possible
Monitor fluid deficit closely and halt the procedure and evaluate for fluid-related complications at absorption thresholds
Maintain intrauterine fluid pressure at or 70 to 80 mmHg [15]
Limit surgical time to <1 hour [16]

These measures are discussed in detail separately. (See "Hyponatremia following transurethral resection or hysteroscopy", section on Prevention".)

Measures specific to hysteroscopy for prevention of excessive fluid absorption include use of a vasoconstrictor. This was illustrated in randomized trials in women undergoing operative hysteroscopy [16-18]. Intracervical injections of a dilute vasopressinsolution (eg, 1 unit per 20 mL normal saline) at two sites around the cervix, 10 mL each, before the procedure compared with placebo resulted in a three-fold decrease in fluid absorption. Blood loss was also decreased.

Other methods of limiting fluid absorption during hysteroscopy have not been widely adopted. Treatment with a gonadotropin-releasing hormone analog reduced deficits in one small randomized trial (n = 17), however, these results have not been further evaluated and the side effects (eg, hot flashes) induced by these drugs may outweigh possible benefits [19]. In addition, to improve detection of fluid absorption, it has been proposed to add an easily measurable tracer to distending media (eg, ethanol) [20,21]. However, this has not proven to improve monitoring [22].

Diagnosis and management of fluid overload—Serious complications of electrolyte-poor fluid overload have been reported at a fluid deficit of 500 to 1000 mL and are more likely to occur in patients with comorbidities (eg, heart disease). Thus, depending upon the type of fluid used and the health status of the patient, when the fluid deficit reaches 500 mL, the surgical team should pause and assess patient status. After estimating the amount of time necessary to complete the procedure, the team should either expedite the completion of the procedure or terminate the procedure.

For nonconductive, electrolyte-poor fluids, the procedure should be terminated when 1000 mL has been absorbed and the patient evaluated for hyponatremia. (See "Hyponatremia following transurethral resection or hysteroscopy", section on 'Prevention'.)

For electrolyte-containing media, the criteria for terminating a procedure are:

2500 mL for younger patients with no comorbidities
For other patients, the threshold must be individualized according to cardiovascular status or other comorbidities

Terminating the infusion at lower thresholds is reasonable in outpatient settings with limited acute care and laboratory services. In addition, all procedures should be terminated if uterine perforation occurs, since large volumes of fluid may rapidly enter the circulation via the peritoneal cavity [13]. (See "Uterine perforation during gynecologic procedures".)

If a criterion for stopping a procedure is met, the following steps should be taken to evaluate the patient:

(1) Halt procedure — discontinue fluid inflow, remove all instruments; if there is active bleeding, a 30 to 50 mL Foley catheter can be inserted in the uterine cavity, inflated, and removed after six to eight hours

(2) Ask about symptoms of volume overload, hyponatremia, or glycine toxicity (in patients who are not under sedation or general anesthesia) — nausea, headache, visual disturbance, prickling or burning sensation in the face and neck, chest pain, shortness of breath [13]

(3) Evaluate hemodynamic status — vital signs, central venous pressure, oxygensaturation

(4) Evaluate mental status

(5) Perform laboratory evaluation — hematocrit, platelets, blood urea nitrogen, creatinine, sodium, potassium, bicarbonate, chloride, glucose, ammonia (glycine is metabolized to ammonia), and plasma osmolality

Evaluation of the patient should be individualized according to a patient's comorbidities. For example, there is a higher risk of sequelae from metabolism of glycine to ammonia in a patient with liver disease. The metabolites of each distending medium are listed in the table (table 1).

Patients who have an excessive fluid deficit but show no signs or symptoms of fluid overload can be observed, but this observation must be continued postoperatively. Plasma dilution peaks at approximately 15 to 20 minutes after fluid infusion, but fluid and electrolyte shifts continue for several hours afterward [13].

If a fluid-related complication is suspected, a management plan must be initiated by the surgeon and anesthesiologist. Depending on the degree of fluid overload or electrolyte imbalance, management may include observation, diuresis, intravenous administration of corrective fluids (eg, hypertonic saline), or hemodialysis. Consultation with a nephrologist or cardiologist, or transfer of the patient to a critical care setting, may be necessary.

Gas embolism—Carbon dioxide or air embolism may occur when carbon dioxide is used for distension, or also, if air bubbles are introduced while using fluid media [4]. Gas embolism can cause cardiovascular collapse.

Prevention of gas embolism—Preventive steps for gas embolism during hysteroscopy include [23]:

Keep the patient in flat or reverse Trendelenburg position
Avoid use of nitrous oxidefor anesthesia (this may enlarge air bubbles)
Purge air from all tubing prior to insertion into the uterus
Maintain intrauterine pressure at <100 mmHg
Limit removal and re-introduction of the hysteroscope (this may force air or gas into the uterus)
Remove intrauterine gas bubbles (ideally with a continuous outflow system)

Carbon dioxide must be insufflated with a special instrument known as a hysteroinsufflator. The laparoscopic insufflator delivers 1 L/min or more of flow and should NEVER be used for hysteroscopy, as a gas embolism may occur.

Hysteroinsufflators can be set to reach a target intrauterine pressure of less than 100 mmHg or to deliver a constant rate of flow of less than 100 mL/min [5,6,23,24].

Diagnosis and management of gas embolism—Dyspnea is the most common symptom; other signs and symptoms are listed in the table (table 2). A fall in a patient's end-tidal carbon dioxide pressure may raise intraoperative suspicion of gas embolism, but may also be present in other conditions [23].

If gas embolism is suspected, the procedure should be terminated immediately, the uterus deflated, and sources of fluid or gas removed [23].

Supportive care (eg, the use of mechanical ventilation, vasopressors, volume resuscitation as indicated) is the cornerstone of management, but active measures may also be helpful. (See "Air embolism".)

Shoulder pain—Infrequently, patients will complain of shoulder pain, likely due to diaphragmatic irritation from carbon dioxide. Symptoms usually subside in less than 15 minutes, without treatment [25].

SUMMARY AND RECOMMENDATIONS

Most hysteroscopic procedures use a fluid or gaseous uterine distending medium to allow a global view. (See 'Introduction'above.)

Operative hysteroscopy can be performed with either monopolar or bipolar electrical energy. Electrolyte-poor fluids are used with monopolar systems. (See 'Fluid media'above.)

Excessive absorption of any fluid medium can lead to complications of fluid overload. The most serious complication is intravasation of large volumes of electrolyte-poor media resulting in hyponatremia. (See 'Fluid overload'above.)

In women undergoing hysteroscopy using a fluid distending medium, we suggest using an automated rather than a manual fluid monitoring system (Grade 2C). (See 'Inflow and monitoring'above.)

In women undergoing hysteroscopy using an electrolyte-poor fluid distending medium:

- For procedures that involve myometrial resection, we recommend an intracervical injection of dilute vasopressinimmediately prior to the procedure (Grade 2B). (See 'Prevention of fluid overload'above.)
- We suggest halting the procedure at a fluid deficit of 1000 mL (Grade 2C). (See 'Diagnosis and management of fluid overload'above.)

In women undergoing hysteroscopy using an electrolyte fluid, we suggest halting the procedure at a fluid deficit of 2500 mL in women who are less than 50 years old and have no comorbid conditions (Grade 2C). For other patients, the threshold must be individualized according to cardiovascular status. (See 'Diagnosis and management of fluid overload'above.)

Use of carbon dioxide for uterine distension requires insufflation with a hysteroscopic insufflator. A laparoscopic insufflator should never be used because it can result in gas embolism. (See 'Gaseous media'above.)

Carbon dioxide or air embolism are rare complications of hysteroscopy. These may occur when carbon dioxide is used for distension, or also, if air bubbles are introduced while using fluid media. Dyspnea is the most common symptom. (See 'Gas embolism'above.)

If gas embolism is suspected, the procedure should be terminated immediately, the uterus deflated, sources of fluid or gas removed, and supportive care provided.

INTRODUCTION—

The development of hysteroscopy has provided a minimally invasive approach to common gynecologic problems, such as abnormal uterine bleeding. Increased clinician training, smaller diameter hysteroscopes, and increased emphasis on office-based procedures have led to a widespread use of this important technology.

A hysteroscope is a telescope that is inserted into the uterus via the vagina and cervix to visualize the endometrial cavity, as well as the tubal ostia, endocervical canal, cervix, and vagina. Hysteroscopy can be performed for diagnostic or therapeutic indications.

An overview of hysteroscopy is presented here. Vaginoscopy is discussed separately. (See "Vaginoscopy".)

INDICATIONS—

Hysteroscopy is performed for evaluation or treatment of the endometrial cavity, tubal ostia, or endocervical canal in women with:

Abnormal premenopausal or postmenopausal uterine bleeding
Endometrial thickening or polyps
Submucosal, and some intramural, fibroids
Intrauterine adhesions
Müllerian anomalies (eg, uterine septum)
Retained intrauterine contraceptives or other foreign bodies
Retained products of conception
Desire for sterilization
Endocervical lesions

There are several approaches to evaluating women with abnormal uterine bleeding or intrauterine lesions (pelvic sonography, saline infusion sonography, endometrial sampling, hysterosalpingography). Using hysteroscopy for the initial evaluation offers the potential benefit of combining evaluation with treatment. Also, hysteroscopy avoids the risk of missing focal pathology, as may occur with blind endometrial sampling.

Alternatively, hysteroscopy can be used to further evaluate or treat lesions identified on imaging studies, or to confirm the absence of disease when symptoms persist and initial diagnostic tests are normal (eg, blind endometrial sampling). Using hysteroscopy to follow-up abnormal imaging findings helps to rule out ovarian or tubal pathology that may contribute to abnormal uterine bleeding.

A detailed discussion of the choice between hysteroscopy and other methods of endometrial evaluation can be found separately. (See "Evaluation of the endometrium for malignant or premalignant disease"and "Endometrial sampling procedures".)

Hysteroscopy cannot assess myometrial disease (eg, adenomyosis), tubal pathology, or the external uterine contour; thus, it is not sufficient for evaluation of these anatomic structures during an infertility evaluation. Additional procedures (eg, laparoscopy or hysterosalpingography) are necessary. (See "Evaluation of the infertile couple".)

CONTRAINDICATIONS

—Contraindications to hysteroscopy are:

Viable intrauterine pregnancy
Active pelvic infection (including genital herpes infection [1])
Known cervical or uterine cancer

While hysteroscopy should not be performed in a patient with a viable intrauterine pregnancy, postpartum or post-abortal hysteroscopy is sometimes useful for evaluation and treatment of retained products of conception [2,3].

Excessive uterine bleeding may limit visualization during hysteroscopy, but it is not a contraindication [4](see 'Operative challenges'below.

Medical comorbidities (eg, coronary heart disease, bleeding diathesis) are also potential contraindications to hysteroscopic surgery. However, since this is a minimally invasive procedure, it is contraindicated in few women. (See "Overview of the principles of medical consultation and perioperative medicine".)

INSTRUMENTATION—The hysteroscope includes an outer sheath which surrounds channels for the telescope, distending media inflow and outflow, and operative instruments. Additional equipment is needed for infusing and monitoring uterine distending media.

There are many different sizes and type of hysteroscopes. Some are better suited for diagnostic versus operative procedures, or for outpatient rather than operating room procedures.

Hysteroscopes

Outer diameter and working length

Outer diameter — The total outer diameter (OD) of a hysteroscope refers to the diameter of the sheath, a metal tube which houses the telescope and instruments. Sheath ODs range from 3.1 to 10 mm.

Smaller OD hysteroscopes cause less pain and decrease the need for mechanical dilation. Even reducing the sheath size from 5 to 3.3 mm can improve patient comfort [5,6]. In general, inserting a hysteroscope with >5 mm OD will require mechanical cervical dilation, and is performed in an operating room; with use of smaller OD sheaths, hysteroscopy can be performed without dilation and in the office.

Both diagnostic and operative sheaths are fitted with stopcocks or ports for the instillation of distending media. To clear blood and thus improve visualization of the uterine cavity, some operative sheaths have dual ports that provide continuous laminar flow of distending media. In addition, some operative sheaths aspirate pieces of tissue from the uterine cavity (ie, to remove debris or retrieve specimens for pathologic evaluation). This allows removal of large debris while maintaining cervical dilation (see 'Distending media'below.

Selected diagnostic hysteroscopes permit targeted biopsies and retrieval of foreign bodies, as well as limited intrauterine surgery (removal of filmy adhesions or small endometrial polyps).

Simple operative sheaths use the distending media channel for the insertion of instruments. Although this method is easy and allows one to use a small-diameter sheath, leaks of media are common.

Advanced operative sheaths may have three channels: two for operative instruments and one for instilling distending media.

Other operative sheaths contain permanently attached operative tools, such as biopsy instruments, forceps, or scissors.

Working length — The working length of a hysteroscope measures from the eyepiece to the distal tip, and can range from 160 to 302 mm. A longer working element permits the hysteroscopist to be further away from the vagina.

Rigid versus flexible—Most hysteroscopes are rigid, but narrow caliber scopes (<5 mm) may also be semi-rigid or flexible. Rigid hysteroscopes cause more intraoperative pain, but offer better optical quality and are less costly. This was illustrated in a randomized trial that assigned 144 pre- and postmenopausal women undergoing outpatient diagnostic hysteroscopy to a 3.7 mm rigid or 3.6 mm flexible hysteroscope [7]. Both groups received topical cervical anesthesia. Compared with flexible hysteroscopes, use of a rigid hysteroscope was associated with significantly more pain, but better optical quality and ease of insertion.

Flexible hysteroscopy is especially useful for diagnostic or operative procedures in women with an irregularly shaped uterus, as the distal tip can be deflected upward or downward (eg, for tubal cannulation or lysis of adhesions near the tubal ostia) (picture 1).

Optics—Quality of visualization varies among hysteroscopic telescopes. In general, the higher quality cameras have larger ODs and are more costly. Thus, narrow caliber telescopes provide adequate quality for routine diagnostic procedures, while the high quality cameras are preferable for advanced operative hysteroscopy.

The telescope consists of three parts: the eyepiece, barrel, and objective lens. The image depends upon characteristics of these components. Hysteroscopes are monocular (single eyepiece), and thus, provide little depth perception. The surgeon can look directly through the eyepiece or view the image via a video monitoring system. Use of a video monitoring system allows other operating room personnel to view the procedure and also allows still photographs and video recordings for documentation.

Viewing angles range from zero to 70 degrees (figure 1). A zero degree hysteroscope provides a panoramic view in line with the sheath. Increasing viewing angles allow the surgeon to visualize areas to the left or right of midline without shifting the telescope from side to side (eg, to view the tubal ostia or a focal lesion in an irregularly shaped cavity).

There are two main hysteroscopic optical systems: direct optical and contact. The direct optical hysteroscope, derived from the cystoscope, provides the surgeon with a global view of the uterine cavity. A distending medium is used and the image is well-illuminated and has excellent contrast and resolution.

Conversely, contact hysteroscopes work without a distending medium and provide only a focal view of the endometrial cavity, since only tissue in direct contact with the scope can be viewed [8]. Thus, unless the uterine cavity is explored in a slow, systematic fashion, significant pathology can be missed. This approach is rarely used.

Light source — Illumination for hysteroscopy is provided by a light source connected to the hysteroscope by a fiberoptic cable. Fiberoptics allow transmission of bright light without the transmission of significant heat.

Most light sources are either halogen or xenon. Either type of lamp provides adequate illumination for operative procedures, photography, and videotaping; xenon lamps are more expensive than halogen.

Operative instrumentation—Operative hysteroscopes are used to remove endocervical or endometrial lesions (eg, submucosal myomas, endometrial polyps) or to perform an endometrial resection. Some, but not all, operative hysteroscopes use electrocautery. Laser is rarely used in modern hysteroscopic procedures. (See "Endometrial ablation", section on 'Standard endometrial ablation techniques'.)

The three types of operative hysteroscopes are:

(1) Operative sheath with instruments inserted through channels or fixed to the sheath

(2) Electrocautery resectoscope

(3) Hysteroscopic morcellator

Operative sheaths — An assortment of flexible, semirigid, and rigid instruments have been developed or adapted for hysteroscopic surgery.

Flexible and semirigid instruments range in diameter from 2 to 3 mm and are inserted through an operating channel in the sheath [9]. These instruments include scissors, grasping forceps, biopsy forceps, and punctate electrodes (picture 2A-B). Semirigid or flexible instruments may be fragile, and must be handled with care to avoid damage.

Rigid instruments may also be inserted through a channel, or may be fixed to the end of the hysteroscope. Fixed instruments are not commonly used, since they must be inserted, removed, and manipulated along with the entire hysteroscope.

Some systems have sheaths which use suction to retrieve tissue fragments without removing the hysteroscope.

Resectoscopes — Resectoscopes typically consist of a 7 to 9 mm sheath [9](picture 3). They use electrocautery and may be monopolar or bipolar.

When a monopolar resectoscope is used, the patient must be grounded and a nonconducting (ie, nonelectrolyte), distending medium must be used. Bipolar resectoscopes are a newer development and can be used with electrolyte distending media, eg,saline or Ringer's lactate [10]. . (See 'Distending media'below and "Overview of electrosurgery".)

Traditionally, electrodes for the resectoscope have included the loop and rollerball (picture 4). Newer vaporizing electrodes (eg, VaporTrode®, Versapoint™) have been introduced that vaporize lesions and thus obviate the need to remove floating pieces of tissue. Of course, they are not appropriate for procedures in which a specimen is needed for histology.

Assembly of resectoscopes generally requires some practice and should be mastered before a surgical procedure is undertaken (picture 5A-D).

Hysteroscopic morcellator — The hysteroscopic morcellator consists of a rotary blade that cuts lesions; tissue is then aspirated through the morcellator [11]. The morcellator is inserted through the working channel of a 9 mm hysteroscope. The morcellator does not use electrocautery, and thus, is not able to coagulate bleeding vessels encountered during surgery.

Distending media—Hysteroscopy is performed using a distending medium to provide a global view of the endometrial cavity.

The most commonly used distending media are low viscosity fluids and carbon dioxide. Carbon dioxide is used for diagnostic procedures. The management of fluid and gaseous distending media are discussed in detail separately. (See "Hysteroscopy: Managing fluid and gas distending media".)

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