**4.1 Hysteroscopic polypectomy**

Uterine polyps are focal endometrial outgrowths that may appear anywhere in the uterine cavity (**Figure 4**). They comprise of a variable amount of glands, stroma and blood vessels. Endometrial polyps are commonly found in combination with AUB. They affect women of reproductive age as well as postmenopausal women. Their underlying aetiology is unsure, but most are benign. Hysteroscopy is the gold standard diagnostic test. Diagnosis at outpatient hysteroscopy allows for simultaneous surgical removal, which is convenient for most women. Polyps should

**Figure 4.** *Hysteroscopic appearance of an endometrial polyp.*

be removed in entirety in women with post-menopausal bleeding because 6% of the polyps harbour atypical endometrial hyperplasia or cancer particularly at the base [18–21].

Video 1 https://youtu.be/HkbCZ318vJ8 outpatient hysteroscopic polypectomy procedure.

Outpatient polypectomy has been shown to be non-inferior to the inpatient procedure [22].

Uterine polypectomy could only be performed in the past using blind procedures, such as curettage and blind avulsion with forceps. To introduce such instruments required dilatation of the cervix and manipulation within the uterine cavity, that necessitated general anaesthesia. Developments in hysteroscopic equipment have enabled polyps to be removed using fine mechanical and electrosurgical tools, which are introduced down a 5- or 7-French rigid operating hysteroscope, and lately, the development of bespoke tissue removal systems. These techniques involve hysteroscopic assessment of uterine cavity, removal of the polyp from the uterine wall and retrieval using the same kit.

The enhanced fastidiousness of surgery and bypassing the requisite for routine significant cervical dilatation have empowered this to become a useful procedure, which can be performed in the office. Often local anaesthesia is not required, especially when using miniature hysteroscopes and employing vaginoscopic technique. Intracervical or paracervical injection of local anaesthesia may be used if cervical dilatation is required [23].

The results of the OPT trial exhibited that outpatient polypectomy was comparable to inpatient polypectomy for the effective mitigation of uterine bleeding due to uterine polyps. At 6 months, 73% of women in the outpatient treatment group and 80% in the inpatient treatment group were effectively cured, and the treatment effects were sustained at 12 and 24 months.

A patient preference study was conducted alongside this RCT which demonstrated a strong treatment setting preference. Nearly, 81% women in this study expressed an inclination for outpatient treatment, and a formal structured interview and thematic analysis established that the overall convenience and feasibility of the outpatient procedure, precluding hospital admission and time off work was highly valued by the women and outweighed the discomfort of the procedure [24].

#### **4.2 Outpatient endometrial ablation**

Heavy menstrual bleeding affects one in five premenopausal women and significantly impairs quality of life. There is evidence to offer endometrial ablation as a first line surgical option for the management of heavy menstrual bleeding. Hysteroscopy and endometrial biopsy should be performed prior to the procedure to rule out any organic pathology and after the procedure to rule out uterine perforation. Endometrial ablation in outpatient setting is associated with shorter hospital stay and quicker recovery. The development of newer (second generation) endometrial ablation techniques has empowered clinicians to set up a comprehensive outpatient service to treat heavy menstrual bleeding effectively without the need for general anaesthetic or conscious sedation. An observational study was performed in ladies with heavy menstrual bleeding who consented to have endometrial ablation in the outpatient setting under local anaesthetic. Once started, the ablation procedure did not have to be abandoned. Eighty-nine percent women went home immediately. Ninety percent expressed that they would have ambulatory hysteroscopic procedure if required in future. Endometrial ablation has conventionally been performed under general anaesthesia as a day case procedure. With new second-generation devices, which enable shorter treatment times, it has become more practical to perform the procedure in outpatient setting. Gynaecologists should continue to offer outpatient endometrial ablation to appropriately selected patients with abnormal uterine bleeding, with adequate counselling regarding possible pain and discomfort and alternative options [25].

Video 2 Novasure® Endometrial Ablation https://youtu.be/I2NOl9xb1os.

### **5. Conclusions**

Hysteroscopy under direct vision can be considered as the gold standard for examination of the uterine cavity, bypassing the significant limitations and possible complications of blind procedures. Modern technological advancements have brought ambulatory hysteroscopy to a mainstay in modern gynaecological practice.

The "see & treat hysteroscopy", has revolutionised the management of abnormal uterine bleeding in all age groups. It has reduced the distinction between diagnostic and operative procedure, introducing the concept of a one step procedure perfectly amalgamating the treatment side with the diagnostic work-up. The use of miniaturised mechanical instruments together with the use of small diameter scopes with working channels and continuous flow systems, has enabled "see & treat" hysteroscopy in the office setting [26].

Outpatient hysteroscopy with direct visualisation represents the optimal diagnostic modality for abnormal uterine bleeding in premenopausal and postmenopausal women as well as treatment option for heavy menstrual bleeding, endometrial polyp, submucosal fibroid type 0 to 2, intrauterine adhesions and uterine septum. It provides cavity assessment in patients with subfertility as well [27]. Most women believe that the overall convenience of the office based procedure outweighs the pain and discomfort experienced and opt for the office procedure if required in future [28]. Hysteroscopy is generally a safe procedure and the uncommon complications such as infection, uterine perforation and fluid overload can be minimised by training, meticulous technique and modern equipment [29, 30].

*Advances in Outpatient Hysteroscopy DOI: http://dx.doi.org/10.5772/intechopen.97093*
