Reviews in Gynaecological Practice最新文献

This review describes the development of the BSGE nurse hysteroscopy training programme over the past 4 years. The programme attracts academic credit and is often a way into the Masters education pathway. A recent survey of qualified nurse hysteroscopists illustrates how much hospitals rely on these individuals for teaching, training and provision of services. All nurse hysteroscopists are working in outpatient hysteroscopy clinics and new developments within the training programme mean that they can now offer treatment as well as diagnosis.

Gynaecological surgery involves risks, predominantly to the woman, though potentially to the staff. This article considers how risks in gynaecological surgery can be avoided or reduced as well as how to learn lessons from adverse events. To do this, the background to risks in healthcare and the theory of reducing error by taking an organisational rather than individual approach to identification and prevention will be discussed. No individual is perfect and punishment does not reduce error. This approach demonstrates that reducing risk requires a combination of prospective and reactive measures.

Having established the basic principles, we consider the approach to gynaecological surgery that minimises risk by ensuring adequate assessment, explanation of risk and that the surgeon and the surgical team are appropriately trained to undertake the task and deal appropriately with problems that arise. The reactive element of reducing risk is to acknowledge adverse outcome as it occurs and to have in place a system to report with a trigger list of events relevant to gynaecological surgery. Then, the root causes which are generally organisational rather than individual are identified to improve practice by learning from the analysis.

Vulvar intraepithelial neoplasia (VIN) is a precancerous skin disorder of the vulva. It is currently classified on the basis of histological findings as VIN1, −2, or −3. Clinically useful tumour markers do not yet exist. Up to 90% of cases of VIN3 are associated with human papillomavirus (HPV). Even with appropriate treatment, approximately 5% of women with VIN3 will develop cancer of the vulva, necessitating appropriate long-term follow-up. The two main aims of management of VIN are to prevent cancer and to resolve symptoms. Research into VIN has been limited by the rarity of the disease. Most data come from published case series focusing on VIN3.

Surgical local excision is a common treatment for VIN2/3. Rotational skin flap procedures are increasingly used when a large area of vulval tissue requires excision. The carbon dioxide laser is also employed for either ablation or excision of high-grade VIN, especially in non-hairy vulval skin. Ablative therapies do not allow histological assessment and unrecognised malignancy may be missed. Medical treatments, such as topical 5% imiquimod cream, or photodynamic therapy with topical 5-aminolaevulinic acid, result in comparatively poor clearance rates of VIN2/3 and long-term outcomes have not been reported. The importance of treatment-related morbidity on sexuality should not be overlooked. HPV vaccines offer an alternative approach. Early work on therapeutic HPV vaccination for high-grade VIN shows that vaccines can stimulate an immune response but not significant clinical improvement. Prophylactic vaccination may be an exciting way to prevent HPV-related diseases, including VIN.

Hysteroscopic and laparoscopic surgery have undoubtedly improved the surgical treatment options available for many gynaecological conditions. However, there are certain operative and post-operative complications which may arise that are directly associated to the minimally invasive approach used. There is limited published data on post-operative complication rates and data rapidly becomes out of date as improvements in equipment, techniques and training are adopted.

The literature on post-operative complication rates directly associated to the minimally invasive approach is reviewed and methods to avoid, identify and treat the various complications are discussed.

Clinicians are encouraged to audit their own complications and large prospective studies examining operative and post-operative complications are needed.

Menorrhagia is a common clinical problem in routine gynaecological practice. Optimal methods for diagnostic work up and therapeutic interventions remain topics for ongoing debate. This can be explained in part by rapid advances in diagnostic and therapeutic technologies. However, the limited quality of available evidence due to inadequate study conception, design and conduct is responsible for much of this uncertainty. Future research should concentrate on a robust approach to the assessment of health technologies used in diagnosis and treatment, so that relevant studies capable of answering well-formulated research questions are designed. Outcomes of importance to patients, namely health related quality of life, should be used as primary outcome measures. Specific areas highlighted for research in this review include the role of particular diagnostic modalities, such as ultrasound and hysteroscopy, in terms of their ability to change patient outcome thorough primary research and decision-analytic modelling. The place of minimally invasive therapies and appropriate utilisation of the outpatient ‘ambulatory’ setting requires clarification through randomised controlled trials. Economic endpoints need to be assessed to facilitate a rational basis on which to allocate resources and upon which to base clinical decisions.