Due to the evolution of hysteroscopic instruments, therapeutic hysteroscopic procedures are increasingly performed in an outpatient, office-based setting. The most important limiting factor of performing these hysteroscopic treatments is patient discomfort. Procedural Sedation Analgesia (PSA) decreases patient discomfort and anxiety. The main goal of this study is to determine safety, feasibility and patient satisfaction of therapeutic hysteroscopy performed under procedural sedation in an outpatient clinic. Our second objective was to compare 9 mm scopes with smaller diameter scopes.
All consecutive patients suitable for procedural sedation and scheduled for a therapeutic hysteroscopy in the outpatient clinic were prospectively included from February 2014 to November 2018 in a teaching hospital in the Netherlands. A variety of therapeutic hysteroscopies procedures was performed including myomectomy, removal of retained products of conception and endometrial ablation. Therapeutic hysteroscopes with 3.8 mm, 5 mm and 9 mm diameter were used. In all selected women procedure time, admission time, pain scores, anaesthesiologic and procedural complications were assessed. All women received a questionnaire on patient satisfaction.
In total 455 patients underwent a therapeutic hysteroscopy. Median procedure time was 11 min (2-63 min) and median admission time was 130 min (30-480 min). Median pain score according to the visual analog scale (VAS) before, during and after procedure were respectively 0 (0-10), 0 (0-4) and 0 (0-9). Anaesthesiologic complication rate was 4.4 %, all minor. Procedural complications consisted of infection postoperatively (0.4 %), excessive blood loss during procedure (0.6 %) and perforation (0.4 %). Procedure was incomplete in 3.3 % of all procedures. Patient satisfaction was high, as 96 % of the women were satisfied. No differences were found in pain scores, VAS 0 versus 1 after the procedure, between 3.8 or 5 mm and 9 mm scopes.
It is safe and feasible to perform a therapeutic hysteroscopy under procedural sedation in an outpatient setting, with low pain scores and a high degree of patient satisfaction, also when large diameter instruments are used.

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