Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
J Minim Invasive Gynecol. 2010 Nov-Dec;17(6):709-18. doi: 10.1016/j.jmig.2010.07.009.
There is a variety of potential advantages to performing hysteroscopically-directed procedures on an awake patient in an office procedure room setting that include increased safety, reduced utilization of resources, and improved patient satisfaction. However, the ideal approach to local uterine anesthesia has/have yet to be determined.
Identification, categorization, and evaluation of published randomized clinical trials (RCTs) comparing local anesthesia to placebo or no treatment for the performance of hysteroscopy.
The Cochrane database of systematic reviews, MEDLINE, and ACP Journal Club were queried for related RCTs. In addition, we located a number of additional studies by identifying and reviewing references in selected papers. These were then reviewed for appropriateness and categorized by allocating them to one of the following types of local anesthesia: Intracervical, paracervical, topical intracavitary, topical cervical, and combined approaches. Each were evaluated for patient factors as well as anesthetic location, anesthetic agent, time from application to procedure, instrument features, and the procedures performed.
A total of 36 studies were identified of which 19 met the criteria for our review; 6 paracervical, 4 intracervical, 7 topical intracavitary, 2 topical cervical; there was also one systematic review of RCTs. Overall, there was substantial heterogeneity in technique in all groups and only with paracervical anesthesia was there a consistent anesthetic effect demonstrated. Many studies were performed with application to procedure times that were less than the time required for maximal anesthetic effect. There were no studies identified where more than one technique was used.
It appears that paracervical anesthesia is useful but the value of other techniques is difficult to evaluate because of limitations of technique and research design. Future investigation should be designed to evaluate longer application to procedure times, a variety of anesthetic agents, concentrations and volumes, and, given the complex innervation of the uterus, strategies that target more than one site. Pain outcomes should be stratified to identify the impact on various components of the procedure. Published studies have largely been limited to diagnostic hysteroscopy so there is also a need to evaluate a greater variety of hysteroscopic procedures.
在办公室环境中对清醒患者进行宫腔镜检查具有多种潜在优势，包括提高安全性、减少资源利用和提高患者满意度。然而，理想的局部子宫麻醉方法尚未确定。
识别、分类和评估比较局部麻醉与安慰剂或不治疗行宫腔镜检查的随机临床试验（RCT）。
检索 Cochrane 系统评价数据库、MEDLINE 和 ACP 期刊俱乐部，以查找相关 RCT。此外，通过识别和审查选定论文中的参考文献，我们还找到了一些额外的研究。然后对这些研究进行了审查，根据将它们分配到以下局部麻醉类型之一的适当性进行了分类：宫颈内、宫颈旁、腔内局部、宫颈局部和联合方法。根据患者因素以及麻醉位置、麻醉剂、从应用到手术的时间、器械特征和手术类型对每个方法进行了评估。
共确定了 36 项研究，其中 19 项符合我们的审查标准；6 项宫颈旁、4 项宫颈内、7 项腔内局部、2 项宫颈局部；还有一篇关于 RCT 的系统评价。总体而言，所有组别的技术都存在很大的异质性，只有宫颈旁麻醉显示出一致的麻醉效果。许多研究的应用到手术时间都少于达到最大麻醉效果所需的时间。没有发现同时使用多种技术的研究。
似乎宫颈旁麻醉是有用的，但由于技术和研究设计的限制，其他技术的价值难以评估。未来的研究应设计评估更长的应用到手术时间、各种麻醉剂、浓度和体积，并且鉴于子宫的复杂神经支配，应采用针对多个部位的策略。疼痛结果应分层，以确定其对手术各个组成部分的影响。已发表的研究主要限于诊断性宫腔镜检查，因此还需要评估更广泛的宫腔镜检查程序。
