1. Outpatient Myosure Audit
Marianne Baithun
Natasha Barbanegra
Viswapriya Sivashnamugarajan
Wasim Lodhi

2. Background
Myosure is a hysteroscopic morcellation procedure that can be done under general anaesthetic or as an outpatient under LA to remove polyps or fibroids

3. Normal saline used
Preserves histology
Simultaneously cuts and suctions maintaining clear view
Single insertion of hysteroscope into uterus unlike traditional hysteroscopic resection
More rapid and therefore reduced risk of fluid overload and less traumatic injury to uterus
Myosure lite recommended for polyps up to 3cm and myosure classic for fibroids up to 3cm and all polyps

4. Payment by Results Guidance 2013/14 has concluded that performing OP procedures offers advantages to both the patient and the provider, due to a quicker recovery allowing patients to get back to work and their daily life sooner.

5. Complications
NICE review of MAUDE FDA database of hysteroscopic morcellation of fibroids:
Approx procedures
Overall reported adverse event rate < 0.1%
Bowel damage- 12 patients (2 needed temporay colostomy and ITU admission)
Serious fluid overload requiring intubation and ITU- 11 patients
Uncomplicated fluid overload resolving spontaneously or with conservative treatment- 19 patients
Uterine perforation not needing additional surgery- 28 patients
Others- bleeding, infection, device failure, poor visualistion, failure of outflow and defective device
In 1 case- blade fell off in cavity and couldn’t be retrieved and patient required hysterectomy

6. RCOG recommendations for OP hysteroscopy
Local anaesthetic is associated with a reduction in pain experienced during outpatient hysteroscopy but its unclear how clinically significant the reduction is.
Routine administration of LA is not indicated.

7. NICE audit criteria (guideline is for fibroids) published June 2015

8. Audit group
28 patients having outpatient myosure procedure between November 2014 to July 2015
Age 26-82
Mixture of retrospective and prospective audit data
Outpatient myosure satisfaction survey carried out in retrospect

10. Results

23. Patient Experience Questionnaire

35. All 16 participated patients responded YES to the following:
Useful verbal information
Happy with the clinic set up/toilet and changing facilities
Chance to ask questions
Friendly and helpful staff
Felt listened by the staff
Felt respected by the staff
All 16 patients responded YES to the following:
Useful verbal information
Happy with the clinic set up/toilet and changing facilities
They had chance to ask questions
Friendly and helpful staff
Felt listened by the staff
Felt respected by the staff

36. Summary of results
Of the 15 with times recorded, 14 had procedure completed in <5 mins
89% success rate
Unable to comment on fluid deficit as not recorded in 18 cases
NICE audit criteria results that we looked at:
Percentage adverse events- 10.7% (3 patients and all were due to device issues or fibroid being too big)
Written consent- 100%
25 patients able to be treated as outpatient avoiding GA and the extra cost of GA procedure

37. Costings £3520 spent on myosure equipment
Government pays £1000 per patient therefore £11200-£14000 extra if done as outpatient
Saving of £25200-£28000 doing under LA rather than GA
Outpatient Myosure for polyps
Myosure as daycase under GA
Cost per procedure £
£1500
Cost for 28 patients
£14000-£16800
£42000

38. Recommendations
Ensure everyone is given trust leaflet prior to procedure when consented in clinic
Pointers for operators:
Need to record operation timing
Need to record fluid deficit
NICE requires ongoing audit of all hysteroscopic morcellation procedures, therefore audit proforma to be filled out for all patients having procedure
Try and follow up patients with phone call after procedure to assess if symptoms have improved and satisfaction with procedure to allow improvements to be made.
NICE recommends follow up of outcomes including symptom relief, quality of life, recurrence rates and information about fertility and subsequent pregnancies.(Beyond scope of audit but potential for research study)