sampling_ aspIrator of endometrial and Vabra curettage A

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					 114          SA MEDICAL JOURNAL 23 JANUARY 1982

 A comparison of endometrial sampling,
 with the Accurette and Vabra aspIrator
 and uterine curettage

                                                                     samI:les of endometrium for histological examination is usually
                                                                     conSIdered mandatory. In asymptomatic women at 'xisk of
       Summary                                                       endometrial hyperplasia or carcinoma, for e*ample
     Endometrial samples were obtained with the                      postmenopausal women on long-term hormone tperapy,
                                                                     endometrial sampling is also considered essential, even'though
     Accurette and the Vabra aspirator and were
     compared with samples obtained' by dilation and                 the risk of hyperplasia or carcinoma is extremely small. At
                                                                     present the use of oestrogens in postmenopausal women is
     curettage in 40 patients with postmenopausal
                                                                     restricted by the lack of a simple, inexpensive, reliable method
     bleeding. The degree of discomfort and patient
     acceptability of the two, outpatient procedures, the            for obtaining endometrial samples for histological and/or
                                                                     cytological examination. The method must cause minimal pain
     adequacy of the samples for cytological and
     histological examination, and the cytological and               or discomfort, be acceptable to patients without anaesthesia or
     histological diagnosis were compared. The                       sedation and be eilsy and convenient to perform as part of the
                                                                     routine gynaecological examination without the need for special
     Accurette and the Vabra aspirator could not be
                                                                     ancillary apparatus such as suction pumps. Once established,
     inserted in 5 out of 40 patients because of cervIcal
                                                                     such a method of endometrial sampling would find widespread
     stenos~s. From approximately 30 of the remaining
                                                                     application in gynaecology as a screening procedure and possibly
     35 patIents, adequate samples were obtained. Six
     cases of endometrial hyperplasia and 3 of                       as replacement in some patients for operative procedures such as
     endometrial carcinoma, were diagnOsed by all the                D and C.
     methods employed, except for 1 case of                             Many methods for obtaining endometrial specimens for
                                                                     ~olo~ical and histological diagnosis have been developed,
     endometrial hyperplasia in \Vhich. the sample
     obtained with the Accurette was inadequate for                  mcludmg the Gravlee Jet Washer, the Isaacs endometrial
     histological examination but was nevertheless                   sampler and the Vabra aspirator. I Vabra aspiration, the most
     adequate for cyto!ogical examination. Of the 5                  widely used method to date, has been shown to be reliable in
                                                                     obtaining endometrial samples for histological examination. 1,2 It
     patients in whom endometrial sampling by both the
     Accurette and the Vabra aspirator could not 't>e                is, however, relatively expensive and requires a separate
                                                                     mechanical pump and is therefore not really suitable for general
     perfor~ed beCause of cervical stenosis, 2 cases of
     endometrial carcinoma were found on uterine
                                                                        The aim of this study was to compare the acceptability and
     curettage. In patients with cervical stenosis,
                                                                     efficiency of the Vabra aspirator and the newly developed
     however, dilatation and curettage under general
                                                                     Accurene in obtaining endometrial samples for cytological and
     anaesthesia is mandatory.
       The AC,curette has the advantage of being less                histological screening and to compare both methods with D and
                                                                     C in a series of patients with postmenopausal bleeding.
     expensive and more suitable for routine
     endometrial sampling for the detection, of
     endometrial hyperplasia or carcinoma and dating of
     toe endometrium in cases of infertility.                        Patients and methods
       Both the Accurette procedure and Vabra
                                                                      Forty patients admitted to Groote Schuur Hospital with
     aspiration' appeared to be reliable methods of
                                                                      postmenopausal bleeding were studied, postmenopausal
     obtaining endometrial samples.
                                                                      bleeding being defined as bleeding per vaginam after at least 12
                                                                      months' amenorrhoea in women aged over 40 years. Endometrial
       S, Atr, med, J,. 61. 114 (1'982),
                                                                      sampling with the Accurette and the Vabra aspirator was
                                                                      performed on the fully conscious patients before D and C under
                                                                      general anaesthesia. The procedure was explained and wrinen,
                                                                      informed consent was obtained from all patients for all three
Endometrial sampling, either as a part of cervical dilatation and     examinations.
uterine curenage CD and C) or as a separate outpatient procedure,        A full description ofthe Accurene and the sampling procedure
is an important part of gynaecological practice, For                  is presented by Kriseman. 3
example, in patients with postmenopausal bleeding who are                Sampling with the Vabra aspirator and vacuum curettage were
suspected of having endometrial disease, D and C to obtain            performed accordin~ to the method originally described by
                                                                      Jensen and Jensen. 1•
                                                                         The procedure was explained to the patients, who were placed
                                                                      in a lithotomy chair. A bivalve speculum was inserted into the
Department of Obstetrics and Gynaecology, University of               vagina and a single-toothed vulsella forceps applied to the
Cape Town and Groote Schuur Hospital, Cape Town
G. L GOLDBERG, M,B. cH.B..Regislrar                                   anterior lip of the cervix. The uterine cavity was gently sounded.
G, TSALACOPOULOS, M.B. CH. B.. M,R.CO,G,. Consulranr                  The curene introducer was inserted into the cervical canal, and
D. A. DAVEY, PH.D,. F.R.CO.G.• Professor and Head of Deparlmenr       the Accurene propelling rod then pushed in until the
                                                                    , quadrilateral head expanded and touched the fundus ofthe uterus.
Date received: 2 November 1981.                                       The Accurene was twis ted round two or three times in the uterine
                                                                               SA MEDIESE TYDSKRIF 23 JANUARIE 1982                  115

cavity and then withdrawn through the introducer. The head
was then smeared on a glass slide which was fIxed with
cytological fIxative. The head was next inserted in a glass tube          TABLE 11. SUCCESS OF ENDOMETRIAL SAMPLING
containing 10% formalin in normal saline and rotated to remove           WITH THE ACCURETTE AND THE VABRA ASPIRATOR
the remainder of the specimen which was sent for histological            AND ADEQUACY OF SPECIMEN FOR CYTOLOGICAL
examination.                                                                    AND HISTOLOGICAL EXAMINATION
   The Accurerte was used fIrst in order to assess adequacy of
                                                                                                      Accurette        Vabra
endometrial sampling by this method. The Vabra aspirator has
been widely used and has been shown to be reliable in obtaining         Total No. of patients                 40           40
endometrial samples for cytological and histological                    Successful procedure                  35           35
      .   .   1,2                                                       Adequate for cytology                 31           30
   The Vabra aspirator was next introduced and Vabracurettage           Adequate for histology                30           31
performed. A cytological slide was prepared by smearing the end
of the Vabra aspirator on a glass slide. The remainder of the
specimen was washed into the special Vabra aspirator container
before fl1ling it with 10% formalin in normal saline.                 discQmfort was during the insertion of the Vabra aspirator. In
   At the end of the procedure the patients were asked to grade       general, the Accurette appeared to cause less discomfort than the
the degree ofdiscomfort experienced at the different stages of the    Vabra aspirator. The number of patients in whom endometrial
examination including introduction of the speculum, the               sampling by Accurette and Vabra aspirator was successfully
application of the vulsella forceps, the insertion of the Accurette   performed together with the number of patients whose
introducer, the Accurette curettage, the insertion of the Vabra       submitted specimens were judged to be adequate for cytological
aspirator, the Vabra curettage, and after removal of all the          and histological examination are shown in Table 11. In 35 our of
instruments.                                                          40 patients (88%) endometrial sampling by both Accurette and
   D and C was performed within 24 hours under general                Vabra aspirator was successfully performed. In 5 patients
anaesthesia using the standard surgical technique, and the            neither procedure could be performed owing to cervical stenosis
curettings obtained were submitted for histologi-::al examination.    and no specimens were obtained. However, in 2 of the 5 patients
   The cytological smears were prepared by standard cytological       in whom endometrial sampling was unsuccessful owing to
techniques and examined by one observer, who was asked to             cervical stenosis, dilatation and curettage also proved
state whether the specimen was inadequate or adequate for             unsuccessful.
examination, and if it was adequate whether - normal
endometrium, endometrial hyperplasia, endometrial carcinoma              Smears which were adequate for cytological examination were
or any other specific abnormality was evident. The three              obtained in 31 patients (89%) by Accurette and in 30 patients
endometrial samples from each patient, prepared by a standard         (86%) by Vabra aspirator. Samples which were adequate for
histological technique, were also examined by one observer who        histological examination were obtained in 30 patients (86%) by
was similarly asked to state whether the specimens were               Accurette and 31 patients (89%) by Vabra aspirator. In 3 our of
inadequate or adequate and, if adequate, to make a diagnosis of       the 5 patients in whom the specimens obtained with both
normal endometrium, endometrial hyperplasia, endometrial              Accurene and Vabra aspirator were inadequate for cytological
carcinoma or 'other specifIc abnormality.                             and histological examination curettings were also unobtainable
                                                                      on D and C. The results of the cytological examination of the
                                                                      smears obtained by Accurette and Vabra aspirator are shown in
                                                                      Table Ill. Both methods of sampling gave identical results and
Results                                                               all 6 cases of endometrial hyperplasia and all 3 cases of
The degree of discomfort experienced by patients during or after      endometrial carcinoma were successfully detected.
the various stages of the procedure is shown in Table 1. It was not
n'ecessary to abandon either Accurette or Vabra aspiration
because of discomfort. No analgesia or sedation was required                   TABLE Ill. COMPARISON OF ACCURETTE AND
either during or after the procedure. Mild bleeding observed in a                           VABRA CYTOLOGY
few patients on completion of the procedure required no                                           Accurette         Vabra
treatment and no other complications were noted. The only part            Inadequate                      4           4
of the procedure when some patients experienced severe                    Absent                          2           2
                                                                          Normal endometrium          20             20
                                                                          Hyperplasia                     6           6
  TABLE I. DEGREE OF DISCOMFORT DURING VARIOUS                            Carcinoma                  J               -2
             STAGE S OF THE PROCEDURE                                       Total                     35             35
                                   Degree of discomfort
Stage of procedure         None       Mild    Moderate Severe
Introduction of
  speculum                   33         1                 0                     TABLE IV. HISTOLOGICAL DIAGNOSIS OF
Application of                                                                   ENDOMETRIAL SAMPLES OBTAINED BY
  vulsella forceps            4        26          5      0                        ACCURETTE, VABRA AND D AND C
Insertion of                                                                                     Accurette         Vabra        D and C
  introducer of
                                                                         Absent                       2 2 10
  Accurette                   0        29          5      1
                                                                         Inadequate                   543
Accurette                     0        12         22      1
                                                                         Normal endometrium          2020 16
Insertion of Vabra            0         8          7     20
                                                                         Hyperplasia                  566
Vabra suction
                                                                         Carcinoma                    335
  curettage                   0         6         22      7
                                                                           Total                     35 35 40
On completion                25         6          4      0

  Results of the histological examination of the endometrial          was reported as showing endometrial hyperplasia. The results
samples obtained by Accurette, Vabra aspirator and D and Care         obtained in the present series therefore appear to be significantly
shown in Table IV. The diagnosis on the specimens obtained by         better than those obtained in previous series using the Isaacs cell
Accurette and Vabra aspirator was identical, except in I case in      sampler and the Vabra aspirator. Endometrial sampling with
which the specimen obtained by Accurene was reported as               both the Accurene and the Vabra aspirator appears to be a
inadequate but the specimen obtained by Vabra aspirator was           reliable means of detecting endometrial abnormalities in all cases
reported as 'endometrial hyperplasia'.                                where the Accurene or the Vabra aspirator can be successfully
                                                                         The only cases in which endometrial carcinoma was missed
Discussion                                                            were in 5 patients with cervical stenosis in whom the procedure
                                                                      failed. It is therefore suggested that D and C under general
  Of the 40 patients on whom D and C was performed, 5 (13%)           anaesthesia is essential in all cases where Accurene or Vabra
  were reported as having endometrial carcinoma. Three of the 5       aspirator insertion is unsuccessful for any reason.
  cases of endometrial carcinoma were also diagnosed                     The Accurette would appear to be as efficient as the Vabra
  independently on cytological smears and on histological             aspirator and to have a number ofsignificant advantages in that it
  examination of the specimens obtained by the Accurene and the       causes less discomfort to patients and is less expensive; also it can
  Vabra aspirator. The 2 cases which were not diagnosed by either     be performed as part of the routine gynaecological exaIDination
  the Accurene or Vabra aspirator occurred in the 5 patients on       without the need for additional apparatus and is therefore more
 whom the procedure failed owing to cervical stenosis. No cases of    suitable for rourine use.
  endometrial carcinoma were missed when endometrial sampling            The availability of a simple, acceptable means of endometrial
 by Accurene and Vabra aspirator was successfully performed.          sampling such as the Accurene may be an important
    Endometrial hyperplasia was correctly diagnosed by both           development, as the incidence of carcinoma of the cervix is
 cytological and histological examination of the specimens            decreasing and that of endometrial carcinoma is increasing. In
 obtained both by the Accurene and the Vabra aspirator on all the     some centres the ratio of cervical to endometrial carcinoma has
 patients, with the exception of 1 specimen which was obtained by     fallen from 6: I to 2: 1. In the USA the incidence of endometrial
 Accurette and which was submitted for histological examination.      carcinoma is now greater than that of cervical carcinoma and it is
 This specimen was judged inadequate for histological                 the commonest neoplasm of the female reproductive tract. 8
 examination but the diagnosis was correctly made from the            Endometrial sampling may thus become an essential part of the
 examination of the cytological smear from this patient. The          routine gynaecological examination in the same way as cervical
 results of cytological and histological assessment of specimens      smears.
 obtained by the Accurette a11d the Vabra aspirator compare              Because of the doubts that have been expressed with regard to
 favourably with those obtained in other series. Hutton er al.,4      the accuracy o(cytological diagnosis of endometrial samples,' it
 using the Isaacs endometrial cell sampler, reported that aspirates   is suggested that all endometrial samples should be submitted if
 satisfactory for cytological diagnosis were obtained in 91 % of      there is sufficient material for histological diagnosis. A
 patients whereas endometrial specimens satisfactory for              cytological smear should also be submitted in case the sample is
 histological diagnosis were obtained in only 79% of patients.        inadequate for histological examination. \Vhere the material
 They concluded that the Isaacs cell sampler was safe, quick,         obtained is obviously inadequate for histological examination, an
 comfortable and reliable for assessing the endometrial slide.        endometrial smear should be made in all cases. Where
 Studd er al.,5 on the other hand, compared the Isaacs cell           endometrial sampling fails and the patient is at risk, e.g. patients
'sampler with Vabra suction curenage and referred each                on oestrogen therapy or with postmenopausal bleeding, D and C
specimen to two independent cytologists and two independent           is mandatory. With such a scheme of management the great
histologists. They found that the histologists agreed with each       majority of patients with endometrial hyperplasia and
other in 75% of cases, the cytologists in 49% and that all four       endometrial carcinoma "Should be reliably detected and
 observers agreed in only 13%. Sturde er al. 6 performed Vabra        diagnosed. Used in this way, the Accurette should enable
 curettage on 348 women receiving various forms of oestrogen          populations at risk of endometrial carcinoma to be screened and
treatment and found that specimens satisfactory for histological      patients on oestrogen therapy for menopausal symptoms to be
 assessment were obtained in 82% of patients. Buchman and             followed up and any endometrial lesions detected at a very early
 Feldman 7 obtained endometrial samples by Novak curene or            stage, enabling appropriate alternative treatment to be
Vabra aspirator in 208 patients receiving oestrogen therapy and       instituted.
obtained specimens satisfactory for histological examination in
 90% of cases; they successfully detected 33 cases of adenomatous
hyperplasia, 2 cases of atypical hyperplasia and 4 cases of             We should like to thank Dr C. M. Durcan for the cytological
endometrial carcinoma. They concluded that the Isaacs cell            examination; Professor A. Tiltman for histological examination of
                                                                      the specimens; Mr D. Watermeyer of Wyeth Laboratories for
sampler with cytological assessment could nor be advocated for
                                                                      supplying the Accurettes and Sister A. Kretzel for her skilled
rourine screening.                                                    assistance.
    In the present series of patients with postmenopausal
bleeding, endometrial samples were obtained by both the
Accurette and the Vabra aspirator in 88% of cases. Of the 35          REFERENCES
patients on whom endometrial sampling was successfully
performed, 30 yielded specimens that were adequate for                 I. Jensen, F. and Jensen, J. G. (1973): Danish med. Bull., 20, 123.
                                                                       2. Jensen, J. G. (1970): Ibid., 17, 199.
cytological and histological examination. In these 30 cases            3. Kriseman, M. M. (1982): S. Afr. med. J., 61, 107 (this issue).
adequate material was subsequently obtained by dilatation and          4. Hutron, J. D., Morse, A. R., Anderson, M. c., er al. (1978): Brit. med. J., 1,
curenage. The only exception was I patient with endometrial            5. Srudd, J. W. D., Thorn, M. and Discher, F. (1979): Ibid., 1,846.
hyperplasia whose endometrial sample obtained by Accurene              6. Srurdee, D. W., Wade-Evans, T., Pa!erson, M. er al. (1978): Ibid., 2, 1575.
                                                                       7. Buchman, M. I. and Feldman, A. B. (1978): Obs!et. and Gynec., 51, 339.
was reported inadequate for histological examination. In ·this         8. Matthews, D. D., Kakani, A. and Bhatracharya, A. (l973):J. Obs!e!. Gynaec.
case, however, the smear submined for cytological examination             Brit. Cwlth, SO, 176.

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