Randomized comparative trial of cervical block protocols for pain management during hysteroscopic removal of polyps and myomas

Andrea S Lukes, Kelly H Roy, James B Presthus, Michael P Diamond, Jay M Berman, Kenneth A Konsker, Andrea S Lukes, Kelly H Roy, James B Presthus, Michael P Diamond, Jay M Berman, Kenneth A Konsker

Abstract

Purpose: To evaluate the efficacy of two cervical block protocols for pain management during hysteroscopic removal of intrauterine polyps and myomas using the MyoSure(®) device.

Patients and methods: This was a randomized, comparative treatment trial conducted by five private Obstetrics and Gynecology practices in the USA. Forty premenopausal women aged 18 years and older were randomized to receive either a combination para/intracervical block protocol of 37 cc local anesthetic administered at six injections sites in association with the application of topic 1% lidocaine gel, or an intracervical block protocol of 22 cc local anesthetic administered at three injections sites without topical anesthetic, for pain management during hysteroscopic removal of intrauterine polyps and/or a single type 0 or type 1 submucosal myoma ≤3 cm. The main outcomes were a composite measure of procedure-related pain and pain during the postoperative recovery period, assessed by the Wong-Baker Faces Rating Scale (0= no pain to 10= maximum pain). The lesion characteristics, procedure time, and adverse events were summarized.

Results: A total of 17 polyps and eight myomas were removed in the para/intracervical block group, with diameters of 1.3±0.5 cm and 1.8±0.8 cm, respectively. In the intracervical block group, 25 polyps with a mean diameter of 1.2±0.7 cm and 7 myomas with a mean diameter of 1.9±0.9 cm were removed. The mean tissue resection time was 1.2±2.0 minutes and 1.2±1.4 minutes for the para/intracervical and intracervical block groups, respectively. The mean composite procedure-related pain score was low for both cervical block protocols, 1.3±1.4 in the para/intracervical block group vs 2.1±1.5 in the intracervical block group. During the postoperative recovery period, the mean pain scores were 0.3±0.7 vs 1.2±1.7 for the para/intracervical and intracervical block groups, respectively. There were no serious adverse events.

Conclusion: The MyoSure procedure for removal of polyps and myomas was well tolerated, with low pain scores reported for both the para/intracervical and intracervical block protocols.

Keywords: MyoSure; hysteroscopic morcellation; myomectomy; polypectomy.

Figures

Figure 1
Figure 1
Para/intracervical block injection sites. Notes: The para/intracervical block group received a total of 37 cc of anesthetic, administered at six injections sites: 2 cc superficially at 12:00; 10 cc at 3:00; and 10 cc at 9:00, in the cervical vaginal junction, superficially through mucosa, approximately 0.5 cm deep; 5 cc at 4:00; and 5 cc at 8:00, approximately 1 to 2 cm deep, halfway between the canal and the lateral edge of the cervix; and 5 cc submucosally at 6:00, between the uterosacral ligaments, approximately 0.5 cm below the cervical vaginal junction. Topical 1% lidocaine gel was applied to the cervix, with a set time of 2 to 3 minutes prior to the injection of anesthetic, for the para/intracervical block group only. Figure provided courtesy of Mark Glasser, MD.
Figure 2
Figure 2
Intracervical block injection sites. Notes: The intracervical block group received a total of 22 cc of 1% lidocaine and 0.25% bupivacaine, administered at three injections sites: 2 cc superficially at 12:00; 10 cc at 4:00; and 10 cc at 8:00, approximately 1 to 2 cm deep. Figure provided courtesy of Mark Glasser, MD.
Figure 3
Figure 3
Hysteroscopic image of the MyoSure® tissue removal device in the uterine cavity. Note: Resection of myomatous tissue with the MyoSure device, midway through the procedure.

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Source: PubMed

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