Jonathan D. Emery Marie Fidela R. Paraiso Editors Offi ce-Based Gynecologic Surgical Procedures 123 Office-Based Gynecologic Surgical Procedures Jonathan D. Emery (cid:129) Marie Fidela R. Paraiso Editors Office-Based Gynecologic Surgical Procedures Editors JonathanD.Emery,M.D. MarieFidelaR.Paraiso,M.D. DepartmentofObstetrics ClevelandClinicLernerCollegeofMedicine andGynecology atCaseWesternReserveUniversity ClevelandClinic Cleveland,OH,USA WilloughbyHills,OH,USA CenterforUrogynecologyandReconstructive PelvicSurgery,Obstetrics,Gynecology andWomen’sHealthInstitute ClevelandClinic Cleveland,OH,USA GlickmanUrologicalandKidneyInstitute ClevelandClinic Cleveland,OH,USA ISBN978-1-4939-1413-5 ISBN978-1-4939-1414-2(eBook) DOI10.1007/978-1-4939-1414-2 SpringerNewYorkHeidelbergDordrechtLondon LibraryofCongressControlNumber:2014949264 #SpringerScience+BusinessMediaNewYork2015 Thisworkissubjecttocopyright.AllrightsarereservedbythePublisher,whetherthewholeor part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,recitation,broadcasting,reproductiononmicrofilmsorinanyotherphysicalway, andtransmissionorinformationstorageandretrieval,electronicadaptation,computersoftware, orbysimilarordissimilarmethodologynowknownorhereafterdeveloped.Exemptedfromthis legalreservationarebriefexcerptsinconnectionwithreviewsorscholarlyanalysisormaterial suppliedspecificallyforthepurposeofbeingenteredandexecutedonacomputersystem,for exclusiveusebythepurchaserofthework.Duplicationofthispublicationorpartsthereofis permitted only under the provisions of the Copyright Law of the Publisher’s location, in its currentversion,andpermissionforusemustalwaysbeobtainedfromSpringer.Permissionsfor usemaybeobtainedthroughRightsLinkattheCopyrightClearanceCenter.Violationsareliable toprosecutionundertherespectiveCopyrightLaw. Theuseofgeneraldescriptivenames,registerednames,trademarks,servicemarks,etc.inthis publicationdoesnotimply,evenintheabsenceofaspecificstatement,thatsuchnamesare exemptfromtherelevantprotectivelawsandregulationsandthereforefreeforgeneraluse. Whiletheadviceandinformationinthisbookarebelievedtobetrueandaccurateatthedateof publication, neither the authors nor the editors nor the publisher can accept any legal responsibilityforanyerrorsoromissionsthatmaybemade.Thepublishermakesnowarranty, expressorimplied,withrespecttothematerialcontainedherein. Printedonacid-freepaper SpringerispartofSpringerScience+BusinessMedia(www.springer.com) Preface Recent trends in medicine have begun to allow for advances in surgical procedures: what were previously surgical procedures performed in the operating room have been transitioned to the ambulatory surgery center and ultimately to the office setting. This movement has been driven by severalforces:improvementsintechnologywithsmallercaliberinstruments; patient’s desire for lesser invasive procedures; rising health care costs with the ability to decrease expenses by performing procedures in less resource- intensivesettings.NationalorganizationssuchastheAdvisoryBoardCom- panyandtheAmericanHospitalAssociationhavenotedthisshiftawayfrom inpatient to outpatient surgery. Since the late 1990s, greater than 60 % of surgicalproceduresintheUnitedStateswerebeingperformedintheoutpa- tientsetting. With this shift in the provision of surgical care in this country, our specialty of gynecology has been fortunate to be a leader in outpatient surgery. In the past 10 years, however, the shift has continued to evolve to the office setting. Gynecologists have been performing office-based procedures for years: colposcopy with cervical biopsy, endometrial biopsy, vulvar biopsy and excision to name a few. Improved technology, however, has allowed for further transition to the office-based setting for more diag- nostic and even therapeutic procedures. Hysteroscopic sterilization is a perfectexampleofthistrend. Therecentgrowthinoffice-basedgynecologicsurgeriescannotbeaccom- plishedwithoutaclearvisionforpatientsafety.IntheUnitedStates,govern- mental agencies and national specialty societies, including the American Congress of Obstetrics and Gynecology, have made patient safety a top priority. Clearly, the transition to office-based gynecologic surgeries must be achieved with patient safety as a primary focus; patient satisfaction is a secondary focus when developing an office-based surgical program. This bookhastwochapterswhichaddresstheseconcerns.Identifyingtheappro- priate patient for an office surgery and then putting in place policies and protocols that emphasize and mandate safe practices will ensure continued success andfurther advancementofoffice-based surgery.Alsoincludedare chaptersrangingfromlong-standingproceduresaswellasnewertechniques adaptedtotheoffice.Eachchaptercontainsadviceandsome“tipsandtricks” thatwillallowgynecologistsandwomen’shealthspecialiststosuccessfully establishtheseproceduresintheiroffices. v vi Preface Anumberofexcellentandwell-regardedtextsofgynecologicsurgeryas well as office gynecology are currently available. There are not, however, textsthatdealwiththespecificsofoffice-basedgynecologicsurgery:thatis what makes this book unique. Our goal for this textbook is to provide gynecologists and women’s health specialists the specifics needed to begin to perform both basic and advanced gynecologic surgeries in the office— fromstarttofinish.Asgynecologists,wehavethedistinctiveopportunityto continuetoadvanceminimallyinvasiveproceduresthatcanmakeasignifi- cant impact on a women’s health, all the while done in the safe and comforting environment of our offices. Our patients deserve the best care from us and we hope this text will continue to allow gynecologists to put “PatientsFirst.” WilloughbyHills,OH,USA JonathanD.Emery,M.D. Cleveland,OH,USA MarieFidelaR.Paraiso,M.D. Contents 1 Pre-procedurePatientEvaluationandManagement. . . . . . . 1 MayHsiehBlanchard 2 GettingStartedinOffice-BasedGynecologic Procedures:OfficeSet-up,ProceduralImplications andEnsuringPatientSafety. . . . . . . . . . . . . . . . . . . . . . . . . 9 NatalieA.BowersoxandJonathanD.Emery 3 InformedConsent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 RuthM.FarrellandCristieM.Cole 4 AnesthesiaandAnalgesiaforOfficeGynecological Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 NicholasMarcanthony,SharonMarcanthony, andEnglokYap 5 BasicGynecologicProcedures. . . . . . . . . . . . . . . . . . . . . . . . 51 M.JeanUy-Kroh 6 SalineInfusionSonohysterography. . . . . . . . . . . . . . . . . . . . 71 JamieStanhiserandRebeccaFlyckt 7 OfficeDiagnosticHysteroscopy. . . . . . . . . . . . . . . . . . . . . . . 85 JonathanD.Emery 8 HysteroscopicTubalSterilization. . . . . . . . . . . . . . . . . . . . . 101 JonathanD.Emery 9 OfficeOperativeHysteroscopy:Polyp andSubmucosalFibroidRemoval. . . . . . . . . . . . . . . . . . . . . 117 MonaE.OradyandRakshandaAslanova 10 Office-BasedGlobalEndometrialAblation. . . . . . . . . . . . . . 133 MargaretL.McKenzieandMoniqueYoder 11 Cystoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 AudraJolynHillandMarieFidelaR.Paraiso 12 UrodynamicTesting. . . .. . . . .. . . . .. . . . .. . . . . .. . . . .. . 149 NathanKowandMarieFidelaR.Paraiso 13 Peri-urethralInjections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 MeganE.Tarr vii viii Contents 14 TriggerPointInjectionsforPelvicPain. . . . . . . . . . . . . . . . . 179 JeannineM.MiranneandAmyJ.Park 15 Colposcopy.. . . . .. . . .. . . .. . . . .. . . .. . . . .. . . .. . . . .. . 191 RobertJ.Kim 16 LoopElectro-ExcisionProcedure(LEEP). . . . . . . . . . . . . . . 211 KimberlyL.LevinsonandChadM.Michener 17 VulvarBiopsyandExcision/Ablation. . . . . . . . . . . . . . . . . . 221 SarahGoodrichandMehdiKebria Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Contributors May Hsieh Blanchard, M.D., F.A.C.O.G. Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine,Baltimore,MD,USA Natalie A. Bowersox, M.D. Department of Obstetrics and Gynecology, FairviewHospital,Brunswick,OH,USA Cristie M. Cole, J.D. Department of Bioethics, Cleveland Clinic, Cleveland,OH,USA Jonathan D. Emery, M.D. Department of Obstetrics and Gynecology & Women’sHealthInstitute,ClevelandClinic,WilloughbyHills,OH,USA Ruth M. Farrell, M.D., M.A. Departments of Obstetrics & Gynecology andBioethics,ClevelandClinic,Cleveland,OH,USA Rebecca Flyckt, M.D. Department of Obstetrics and Gynecology & Women’sHealthInstitute,ClevelandClinic,Cleveland,OH,USA Sarah Goodrich, M.D. Department of Gynecologic Oncology, Cleveland Clinic,Cleveland,OH,USA Audra Jolyn Hill, M.D. Department of Obstetrics and Gynecology & Women’sHealthInstitute,ClevelandClinic,Cleveland,OH,USA MehdiKebria,M.D. DepartmentofObstetricsandGynecology,Cleveland Clinic,Cleveland,OH,USA Robert J. Kim, M.D. Department of Obstetrics and Gynecology, John A. BurnsSchoolofMedicine,UniversityofHawaii,Honolulu,HI,USA NathanKow,M.D. DepartmentofObstetricsandGynecology&Women’s HealthInstitute,ClevelandClinic,Cleveland,OH,USA KimberlyL.Levinson,M.D.,M.P.H. DepartmentofObstetricsandGyne- cology &Women’s Health Institute,The Cleveland Clinic, Cleveland, OH, USA Nicholas Marcanthony, M.D. Department of Anesthesiology, Cleveland Clinic,Cleveland,OH,USA Anesthesiology Institute, Cleveland Clinic Wooster, Cleveland Clinic, Cleveland,OH,USA ix