One-stop outpatient hysteroscopy

Richard Penketh

Anna Denereaz

Ed Holyoak, Boston Scientific


Cardiff and Vale University Health Board


This Bevan Exemplar project introduced a novel tool to facilitate the removal of polyps and improve patient experience.


Background


Polyps inside the womb are associated with abnormal vaginal bleeding; the management traditionally requires three separate hospital visits. Women are referred to hospital and are assessed at their first visit with an examination and an ultrasound scan. The second hospital visit confirms the diagnosis by passing a small telescope (hysteroscope) through the cervix to visualise the polyp and the third visit removes the polyp using a much larger telescope and electrosurgery under local anaesthetic.


Resectr TM is a small single use hand powered mechanical morcellator used for removal of polyps, extracting the tissue down the shaft of the device. The device can be used on the second patient visit, reducing the number of hospital visits required, thereby improving overall patient experience.


Aims

  • Identify 50 suitable patients on whom to use the Resectr TM device.

  • Use the Resectr TM device to facilitate polyp removal at the second patient visit.

  • Improve the patient pathway providing benefits for the patient, the Health Board and clinicians.

  • Reduce the overall number of visits to hospital required by the patient.

  • Use the success of the process to assist Health Boards with low uptake of outpatient hysteroscopies to move away from theatre under general anesthetic.

  • Observe patient experience and surgeon feedback during device use followed by an independent assessment of patient experience by an independent organisation.


Challenges

  • A delay in device acquisition owing to unlisted product and 2 for 1 offer.

  • Tissue separation from fluid extracted as tissue trap holes too large; solved with the purchase of filter paper.

  • Identifying suitable patients; balancing the time pressure of a diagnostic slot against planning a longer appointment ‘just in case’.

  • Identifying suitable polyps; too big? too hard? Too vascular?

  • Resectr TM fits down the inflow channel of the telescope restricting cross sectional area along the entire length of the channel as compared to the smaller shaft of fixed instruments = less flow = loss of vision = failure to complete the removal.


Outcomes

  • The device was used on 10 patients.

  • Patients reported that pain scores and the procedure were acceptable.

  • There was a failure to remove polyp completely in several cases; due to patient selection and equipment teething problems.

  • The device can be effective but careful patient selection is needed. Ongoing evaluation of its use is required.

  • This has been further compounded by the recent news that the company will no longer support CE marking of the device in Europe and Resectr is being withdrawn in 2020.


Next steps

  • Solve the purchasing issues for new technology devices in the Bevan Exemplar projects and other innovations.

  • Utilise the experience of diagnostic and operative hysteroscopy under local anaesthetic available at this Health Board to support those Health Boards who are still doing most of their diagnostic and operative hysteroscopies in theatre under General Anaesthetic to make the transition to outpatients. This will put women at the centre of their care avoiding admission to hospital and the side effects of G.A.



Part of cohort Bevan Exemplar Projects 2018-19