[Personal experience with thermoablation of the endometrium with the Thermachoice balloon catheter]

OBJECTIVE

To evaluate our first experience with thermal balloon therapy of abnormal uterine bleeding.

DESIGN

Prospective study.

SETTING

Department of Obstetrics and Gynaecology, 1st Medical Faculty, Charles University, Prague.

METHODS

Ten procedures of balloon thermal endometrial ablations were performed between November 1998 and February 1999. From ten patients with abnormal uterine bleeding, 4 patients with concomitant polymorbidity (sclerosis multiplex, hypertension, hepatopathia, pyelonephritis) where more invasive intervention was not recommended or was contraindicated. Treatment entailed controlled heating of intrauterine balloon. Local anaesthesia-paracervical block with analgosedation was employed in 50% of procedures and general anaesthesia was employed in 50% of cases. Follow up after 3, 6, 12, 24 months is required. Success was defined as the reduction of menses to eumenorrhoea or less.

RESULTS

Preliminary results after 6 months follow up are successful in 100%; in 5 (50%) cases we recorded amenorrhoea, in 2 (20%) cases hypomenorrhoea and in 3 (30%) cases eumenorrhoea.

CONCLUSION

Thermal balloon endometrial ablation appears to be safe due to its minimal invasivity especially in patients with abnormal uterine bleeding with concomitant polymorbidity.

Absence of flow velocity waveform changes in uterine arteries after bilateral internal iliac artery ligation

A case is reported of bilateral internal iliac artery ligation during cesarean delivery for intractable hemorrhage. Uterine artery Doppler flow velocity waveforms were documented before and after the procedure. After the ligation the uterine arteries could still be visualized in the appropriate anatomic location, and no changes in Doppler flow velocity waveforms were documented.

Thermal balloon ablation versus endometrial resection for the treatment of abnormal uterine bleeding

This study compares the clinical efficacy and safety of a thermal uterine balloon system with hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding. In all, 147 women were treated by two experienced gynaecological surgeons: one performed 73 thermal balloon ablations and the other 74 endometrial resections between November 1994 and April 1998. The inclusion criteria were similar in both groups. The operative time was reduced significantly with the uterine balloon technique. There were no intra-operative complications in either group and postoperative morbidities were minimal and not statistically different. Multivariate analysis noted two prognostic factors associated with failures: retroverted uterus with thermal balloon ablation and age under 43 years with endometrial resection. The overall success rate did not differ significantly between the two groups 83.0 +/- 5% for balloon ablation and 76.3 +/- 6% for endometrial resection. Uterine balloon ablation appears to be as efficacious as endometrial resection. The former is much easier to perform, making the technique readily reproducible, especially by those with limited expertise in hysteroscopic surgery, and thus more widely applicable and safer.

Post-hysteroscopic ablation reaction: a histopathologic study of the effects of electrosurgical ablation

Ablation of the endometrium is now an established treatment modality for dysfunctional uterine bleeding (DUB). There have been few reports of the inflammatory and healing reaction within the endomyometrium subsequent to this therapy, and its identifying characteristics. The morphologic reaction after electrosurgical ablation in particular has received scant attention. In this retrospective study, 19 women were identified who had undergone both an endometrial ablation using electrosurgical rollerball ablation and a subsequent endometrial sampling or hysterectomy. The average age of the patients was 47 years (range, 28 to 60). Fifteen patients had been ablated for DUB, while four had been ablated immediately after a resection that later revealed atypical hyperplasia. Histopathologic specimens were examined from 1 to 48 months postablation. The six specimens examined at 3 months or less after ablation all exhibited necrotic myometrium, and in five of these six cases, a florid foreign body and granulomatous reaction to necrotic myometrium and spicules of thermally damaged myometrium. A variable degree of acute inflammation was evident in all six cases and was exclusively present in one case. The remaining 13 cases were examined at > 3 months posttreatment. Necrotic myometrium was no longer evident, but a persistent granulomatous, a foreign-body reaction, or both was detected in 5 of 12 cases up to 16 months postablation. In most cases (9 of 12), there was striking endometrial scarring. The morphologic response of the endometrium after electrosurgical endometrial ablation is similar to that reported previously for both resection and laser ablation. Post-hysteroscopic ablative reaction should be recognized and distinguished from other causes of granulomatous endometritis.

[Intravascular leiomyomatosis of uterine origin. a case of pseudo-metastatic cavo-cardial thrombus]

BACKGROUND

Leiomyomatosis is a benign smooth muscle tumor which can provoke serious complications in case of intracaval or intracardiac extension.

CASE REPORT

A 61-year-old woman had undergone hysterectomy at the age of 45 years for a hemorrhagic fibroma. She underwent surgery for infiltrative breast cancer 3 months before hospitalization and was taking tamoxifen 30 mg/day. In the cancer context, the diagnosis of cavo-cardiac metastatic thrombus was proposed but not confirmed at pathology. The diagnosis of uterine tissue intravascular leiomyomatosis was established on the basis of pathology findings and immunohistochemistry results.

DISCUSSION

Five other cases of leiomyomatosis after hysterectomy have been reported in the literature.

A case of progressive congestive heart failure secondary to severe anemia in a patient presenting with uterine hemorrhage

In this report, we present a 42-year-old female patient who was transferred to our emergency department due to symptoms of congestive heart failure. She presented with severe anemia (hemoglobin was 1.3 g dl(-1), and hematocrit was 6.0%) due to continuous uterine hemorrhage and metabolic acidosis, otherwise she seemed to be free from illness. We diagnosed that she was suffered from chronic severe anemia due to uterine hemorrhage and congestive heart failure. Monitoring her hemodynamic status, treatment of congestive heart failure using diuretics and inotropes in combination with blood transfusion brought her good recovery. We discussed this case from the mechanisms of development of congestive heart failure in a chronic severe anemic condition, and pointed out that distributive effects of sodium and water may develop congestive heart failure without myocardial dysfunction in such a condition.

Histologic studies of the effects of circulating hot saline on the uterus before hysterectomy

STUDY OBJECTIVE

To evaluate a new device for endometrial ablation.

DESIGN

(Canadian Task Force classification II-1).

SETTING

University-affiliated hospital.

PATIENTS

Thirty-two women scheduled for hysterectomy.

INTERVENTIONS

Endometrial ablation and hysterectomy.

MEASUREMENTS AND MAIN RESULTS

The new device for endometrial ablation was evaluated by studying depth of necrosis after staining for the oxidative enzyme NADH. Uniform endomyometrial necrosis was achieved at a depth of 2 to 4 mm with 90 degrees C saline circulated for 10 minutes.

CONCLUSION

The procedure was successful in all patients, and there were no adverse clinical sequelae. (J Am Assoc Gynecol Laparosc 6(3):269-273, 1999)

[Clinical observation of hysteroscopic electric resection: an analysis of 36 patients with abnormal uterine bleeding]

OBJECTIVE

To assess the efficacy and influences of hysteroscopic electrosurgery in treating abnormal uterine bleeding (AUB).

METHODS

36 women with AUB received hysteroscopic transcervical resection of the endometrium or intrauterine lesions with a continuous flow resectoscope.

RESULTS

The complications rate was 8.3%. 32 patients were followed for 4 to 12 months. Menstrual symptoms ameliorated in 82.4% of the patients. 5.9% of the women became amenorrhoeic. 58.8% had only spotting, 17.6% recovered normal period. 6 out of the 8 cases with dysmenorrhea had relieved their pain. Satisfactory rate of the procedure was 76.5%. Two patients received hysterectomy later for recurrent uterine bleeding.

CONCLUSION

Hysteroscopic electrosurgery is an effective procedure in treating abnormal uterine bleeding. But its long-term efficacy is yet to be identified. When improving the technique and basic knowledge, the indications should be given appropriatly.

[Study on the electrothermal tissue effects during transcervical resection of endometrium]

OBJECTIVE

To investigate the tissue electrothermal effects and to seek the appropriate setting of operative wattage during transcervical resection of endometrium (TCRE).

METHODS

The power setting were 60 W, 80 W, 100 W for cutting and 30 W, 60 W, 80 W, 100 W for coagulation when performing endometrial resection in vitro or in vivo with operating time 3-5 seconds or 6-8 seconds respectively. After operation the uterine specimens were stained by hemaloxylin-eosin, and respiratory enzyme dehydronicotinamide adenine dinucleotide phosphate diaphorase methods for evaluating the tissue damage.

RESULTS

(1) The depth of endometrial damage under cutting was considerably less severe than those under coagulation with the same power setting. (2) When the power of cutting and coagulation were 80 W, 100 W and 30 W, 60 W respectively and operating time prolonged more than 5 seconds, the thermal damage covered endometrium and 2-3 mm of myometrium in depth. (3) At such wattage and operating time the deepest destruction was only 16.27% of uterine wall.

CONCLUSION

(1) There is significant difference in the depth of thermal damage between cutting and coagulation during hysteros copic surgery. (2) The appropriate power setting should be 80-100 W for cutting and 30-60 W for coagulation.

Treatment of recurrent bleeding disorders during hormone replacement therapy by transcervical endometrial ablation

If bleeding disorders, which could not be treated by modification of steroid dosages, occurred during sequential hormone replacement therapy (HRT), most of the patients stopped HRT. In these cases a diagnostic outpatient hysteroscopy with biopsy was carried out. In most of the cases no intrauterine cause for the bleeding disorder was found. In 35 patients we performed an endometrial ablation without intra- or postoperative complications. After this procedure all patients received a combined continuous HRT. In a follow-up of 12 months 34 patients were amenorrheic and satisfied with the treatment. One patient stopped HRT because of suffering from other side effects. Endometrial ablation represents a method of treating patients with bleeding disorders without intrauterine causes with a minimal invasive procedure. A continuous combined HRT is possible after the endometrial ablation in perimenopausal and postmenopausal patients without bleeding disorders. In selected cases endometrial ablation can contribute to the increase of the compliance with HRT.

Morphological changes in hysterectomies after endometrial ablation

Electrosurgical ablation of the endometrium is a therapeutic choice for those patients having abnormal uterine bleeding. When ablation is followed by a hysterectomy, tissue damage due to thermal effect can be seen. From a total of 350 women with endometrial ablation, 12 required subsequent hysterectomy. The histological features found in these specimens are described and related to the elapsed time between the two surgical procedures. The mean elapsed time between ablation and hysterectomy was 19 +/- 17.3 months. Scarring with formation of additional endometrial cavities was seen in five cases, and endocervical stenosis in two cases. In seven patients, endometrial regrowth was seen at hysterectomy. Necrosis, granulomatous and foreign-body giant cell reaction, eosinophilic infiltrate and pigment-containing macrophages in the myometrium were seen in the long-term post-ablation hysterectomies. Necrosis was seen in short period post-ablation hysterectomies. Six of the seven patients with endometrial regeneration had adenomyosis in the hysterectomy specimen. Endometrial ablation induces thermal effects in the endometrium and granulomatous reaction with foreign-body giant cell reaction, fibrosis and deposition of pigment within macrophages in the myometrium. Adenomyosis is a possible explanation for endometrial regeneration in cases of ablation failure.

Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams

OBJECTIVES

The purpose of this study was to compare the surgical outcomes of women with moderately enlarged uteri undergoing vaginal hysterectomy with those of women with uteri of normal size undergoing vaginal hysterectomy. A secondary objective was to investigate the roles of uterine morcellation and laparoscopically assisted vaginal hysterectomy in the treatment of these women.

STUDY DESIGN

Thirty consecutive women during a 2-year period with uterine enlargement to a weight of between 200 and 700 g underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy limited to lysis of adhesions or adnexectomy. These patients with uterine enlargement (group 1) were compared with 160 women with uteri weighing <200 g who also underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy during the same interval (group 2). The 2 groups were compared for total complications, operative time, hospital stay, perioperative hemoglobin concentration change, and use of vaginal uterine morcellation and laparoscopically assisted vaginal hysterectomy.

RESULTS

Operative time for vaginal hysterectomy was significantly longer for women in group 1 than for women in group 2 (66.6 +/- 26.2 minutes vs 53.0 +/- 25.5 minutes, P =.008). There was a linear relationship between uterine weight and operative time: Operative time = 47.156 + 0.056 x Uterine weight (r = 0.20, F = 7.66, degrees of freedom 1, 188, P = .006). Vaginal morcellation of the uterus was needed in 80.0% of the women in group 1 and in 10.0% of the women in group 2 (P < .001). Two women in group 1 (6.7%) and 9 women (5.6%) in group 2 had laparoscopically assisted procedures for lysis of adhesions, adnexectomy, or both, unrelated to uterine size (P =.69). There were no significant differences between the 2 groups with respect to perioperative hemoglobin concentration change or hospital stay. Finally, the rates of major surgical complications were similar in the 2 groups (3.3% in group 1 vs 4.3% in group 2, P > .99, 95% confidence interval -8.1% to 5.9%).

CONCLUSIONS

Although vaginal hysterectomy requires a modest increase in operative time, it is as safe and effective for the woman with a moderately enlarged uterus as for the woman with a uterus of normal size. Vaginal uterine morcellation is the key to a successful operation and obviates the need for either abdominal or laparoscopically assisted hysterectomy solely to deal with moderate uterine enlargement.

Hysterectomy as treatment for dysfunctional uterine bleeding

The surgical treatment of patients with dysfunctional uterine bleeding (DUB) is discussed in this chapter, including indications, techniques and complications. Hysterectomy is the definitive treatment for DUB; in most studies it has a higher rate of patient satisfaction than does hysteroscopic endometrial ablation. The vaginal or laparoscopic approach should be selected in this group of patients with small uteri, while laparotomy is seldom indicated. In general, the indications for vaginal hysterectomy and endometrial ablation differ from those of laparoscopic hysterectomy. Ablation and vaginal hysterectomy are done for hypermenorrhoea, while laparoscopic hysterectomy is best when pathology is present, usually adhesions, endometriosis or fibroids.

[Impact of adenomyosis on results of endometrial ablations]

The authors report the results of a retrospective series concerning 121 patients who presented abnormal uterine bleeding resistant to progestogen therapy. These patients were adenomyosis carriers and who underwent loop endometrial ablation. Over a maximum period of 8 years, the success rate was 56% following one endometrial resection and 67% following one or two resections. The study recorded a repeat resection level of 11%. Seventeen hysterectomies (19%) were performed because of the recurrence of abnormal uterine bleeding. These results are comparable to those observed in endometrial ablation performed for menorrhagia, all benign etiology included. Adenomyosis does not appear to be a factor in the failure of endometrial ablation, except in the case of deep adenomyosis which is difficult to diagnose pre-operatively.

Long-term results of hysteroscopic myomectomy for abnormal uterine bleeding

OBJECTIVE

To analyze the efficacy of transcervical resection of submucous myomas and to identify prognostic factors for long-term results.

METHODS

Two-hundred eighty-five women were treated with transcervical resection of submucous myomas without endometrial ablation. In case of incomplete resection a repeat procedure was offered. Long-term follow-up was obtained. Recurrence was defined as the need for further surgery. The relation of several variables with the outcome was analyzed using Cox proportional hazard regression analysis.

RESULTS

Seventeen cases (6%) were lost to follow-up. The median follow-up was 46 months (range 1-104 months); for cases without recurrence median follow-up was 42 months (range 16-104 months). Forty-one (14.5%) patients had repeat surgery. An independent prognostic value of uterine size (P < .001) and number of submucous myomas (P < .001) for recurrence was noted. Twenty of 41 patients who had repeat surgery subsequently had a hysterectomy. None of the variables investigated predicted the need for hysterectomy. The surgery-free percentage of 165 patients with normal sized uteri and not more than two myomas was 94.3% (standard error +/- 1.8%) at 2 years and 90.3% (+/- 3.0%) at 5 years.

CONCLUSION

Transcervical resection of submucous myomas is a safe and effective treatment for patients with a normal sized uterus and not more than two myomas. It is an acceptable alternative for selected other patients. The need for a combined endometrial ablation is questionable. Transcervical resection of submucous myomas will give patients a high chance of averting further surgery and should modify the way patients are counseled.

Thermal balloon endometrial ablator: a preclinical safety and effectiveness study

OBJECTIVE

To evaluate the preclinical safety and efficacy of the thermal balloon endometrial ablator (TBEA).

METHODS

Informed consent was taken from all patients for TBEA and hysterectomy at same sitting. TBEA was performed in vivo just before hysterectomy on 6 patients' uteri to determine uterine rupture, perforation and thermal damage to surrounding viscera and peritoneum. Temperatures in the pouch of Douglas, uterovesical peritoneum and serosa of uterus were taken by a sterile laboratory thermometer to note for any rise in temperature before, during and after the procedure. The extirpated uteri were then examined grossly for the nature and extent of thermal damage which was visible as a zone of erythema in the endomyometrium. Five extirpated uteri, 3 from the above group and 2 on whom TBEA was performed 3 months ago were histopathologically examined to study the nature and extent of damage to endomyometrial cells. A 5 mm longitudinal strip of uterus along with both the cornual ends were sectioned in such a way that it was representative of the entire uterus.

RESULTS

There was no evidence of uterine perforation, rupture or any damage to the surrounding viscera and peritoneum. There was no rise in temperature in most sites while TBEA was performed. The only area that felt warm was the surface of the uterus and there too the measured rise was only 1 degree C. On gross examination the zone of erythema measured 5.4 mm (mean) (range 3-9 mm). In those uteri subjected to histopathology immediately after TBEA early evidence of thermal damage was visible as hemorrhage, congestion, edema, eosinophilic infiltration and necrosis in 2 out of 3 cases. Late changes of thermal damage after TBEA were seen as basal endometrium and areas of hyalinization. The changes in general were patchy and not uniform.

CONCLUSIONS

TBEA is a safe device with no thermal damage to uterus and surrounding viscera. The mean zone of thermal damage in the endomyometrium is 5.4 mm. On histopathology, the early changes of thermal damage are hemorrhage, congestion, edema, eosinophilic infiltration and necrosis and the late changes are visible as areas of hyalinization and presence of basal endometrium.

A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years. Aberdeen Endometrial Ablation Trials Group

OBJECTIVE

To assess the long term impact of initial management by endometrial ablation for women with dysfunctional uterine bleeding who would otherwise have had a hysterectomy.

DESIGN

Long term follow up of randomised cohorts of women.

SETTING

Gynaecology department of a large teaching hospital.

SAMPLE

Two hundred and four women who had joined a randomised comparison of endometrial ablation with hysterectomy, 4 to 5.6 years previously.

METHODS

Postal questionnaire and casenote review.

MAIN OUTCOME MEASURES

Women's satisfaction with treatment, gynaecological symptoms and psychological outcomes at four years; further surgical treatment and differential resource use at a minimum of four years' follow up.

RESULTS

Further surgical treatment was received by 39 (38%) women randomised to endometrial ablation, including six women who each had two additional treatments. At four years, the probability of receiving further surgical treatment by any method was 36% and by hysterectomy was 24% (compared with 29% and 14% respectively at one year). Satisfaction rates were high (80% ablation group vs 89% hysterectomy group), the difference reflecting re-treatment. Premenstrual symptoms improved over time but more so in the hysterectomy group, who also rated their improvements in general health higher. The estimated overall mean cost of the endometrial ablation group is 93% of that of the hysterectomy group (pound sterling 1231 vs pound sterling 1332).

CONCLUSIONS

While about two out of every five women allocated to endometrial ablation eventually received further surgical treatment, hysterectomy with its associated morbidity was still avoided by 76% of women with dysfunctional uterine bleeding who would otherwise have had a hysterectomy. At four years, the difference in the costs of endometrial ablation and hysterectomy policies had narrowed.

[Endometrial ablation: prospective 3-year follow-up study]

INTRODUCTION

Patients with persistent uterine bleeding not responsive to conservative therapy may in selected cases opt for endometrial ablation rather than hysterectomy.

METHODS

50 women with intractable uterine bleeding were subjected to endometrial ablation. 26 patients were treated preoperatively with danazole 200 to 400 mg/day for 4 weeks, 4 received progestins, 5 norethisteron acetas to stop the acute preoperative bleeding and 15 were not given preoperative treatment. Under anaesthesia the cervix was dilated to 10 mm and the uterine cavity was distended with Purisol (sorbitol and mannitol). Roller-ball coagulation technique combined with loop resection was used in 32 patients, resection using the electrosurgical loop in 17 and coagulation with roller ball in 1 patient respectively. The endometrium of the internal os of the uterus was resected in 16 cases. The findings of small uterine myoma(s) were not considered a contraindication of endometrial ablation.

RESULTS

Patients' satisfaction with the effect of treatment was recorded in 48 cases (96%). After 35--5 months 22 (44%) patients reported amenorrhea, 24 (48%) hypomenorrhea, 3 (6%) eumenorrhea and 1 (2%) no change. The mean time of operation was 25 minutes (range 15-40 minutes). The procedure was completed in all 50 women and we had no serious complications.

DISCUSSION

There was some evidence of superior health related quality of life among hysterectomy patients reported in literature. The rate of secondary hysterectomy was 10% because of associated lesions: myoma with adenomyosis in 50% of the cases, so that the procedure in cases of myoma(s) is questionable. This is the reason why it is necessary to make a careful selection of patients who are to be treated by this metod in order to avoid complications and secondary hysterectomy.

CONCLUSION

It is concluded, that endometrial ablation is a safe and effective hysteroscopic procedure in cases of abnormal uterine bleeding in women with normal uterine morphological findings or small uterine myoma(s).