Surgical aspects of removal of Essure microinsert

Could the anatomic location of Essure® device explain the impairment of quality of life?

BACKGROUND

Since health-related quality of life (HRQL) could improve after removal of Essure^® (Bayer, Leverkusen, Germany) inserts in symptomatic patients, we aimed to assess whether such postoperative enhancement was linked to the anatomic placement of the device.

METHODS

Correct and incorrect placed Essure^® (Bayer) were identified in the electronic database of the French cohort Ablimco (cohort of consenting patients with laparoscopic Essure^® [Bayer] removal). HRQL, pain and heavy menstrual bleeding were evaluated after Essure^® (Bayer) removal with validated quality of life questionnaires (Short Form12 Questionnaire, Visual Analogue Scale, French version of the McGill Pain Questionnaire and the pictorial blood assessment chart PBAC).

RESULTS

Sixty-five patients were included in the study divided in two groups (group A with correct placement: 45 patients and group B with incorrect placement: 20 patients). HRQL and Pain Index were improved in both groups at 6 months post-surgery. There was not any statistically significant difference between group A and B. The PBAC score increased at 6 months postoperatively in group A and B without any statistically significant difference between them.

CONCLUSIONS

Postoperative improvement of quality of life and pain index was similar whatever the position of the implant. This suggests that symptomatology and quality of life are not related to the anatomic location of the Essure^® (Bayer) implants.

Surgical techniques for the removal of Essure® microinserts: a literature review on current practice

PURPOSE

To evaluate the different techniques for Essure^® microinserts removal and to assess the risk of fracture of the device and the intra- and post-operative complications in relation to surgical technique variants.

METHODS

Electronic search in Medline, Scopus and Embase databases using the following keywords: Essure; Essure removal; Essure surgical technique.

RESULTS

Out of 95 articles in the initial database, 17 studies were eligible for inclusion in our literature review. Several surgical techniques have been described in which the most frequent were laparoscopic salpingectomy (LS), laparoscopic cornuectomy (LC), laparoscopic or vaginal hysterectomy (LH, VH) with en-bloc salpingectomy. There were more fractures of the device with the LS procedure (6.25%) followed by the LC technique (2.77%), while there was no fracture with hysterectomy. However, peri-and post-operative complications were more severe and frequent with hysterectomy in comparison with the LC and LS procedures (respectively 8.1% Clavien Dindo grade 3 for the hysterectomy group, 1.11% for the LC procedure and 0.69% for the LS technique).

CONCLUSION

Due to the lack of standardised surgical treatment guidelines, a system of care networks for symptomatic patients with adverse effects related to Essure^® headed by specialised centres may offer a suitable and high-quality management with the appropriate removal techniques within two objectives: limiting the risk of fracture (with an en-bloc removal of the Essure^® microinserts) and avoiding intra- and post-operative complications.

Challenges in Removing the Essure® Device

We present a case about Essure^® removal surgery in which the third markers of the device have torn off. The woman needed a second surgery for complete removal of the devices. Fluoroscopy during surgery is a good method to visualize the lost fragments. With fluoroscopy, a hysterectomy is not needed for complete removal. It is important to understand the structure of the device and to be aware of the four radiopaque markers during surgery and their removal.

Symptom related to Essure® and evolution after removal: Outcomes of retrospective cohort

INTRODUCTION

The number of requests for Essure removal has grown continually over recent years. The objective is to describe the symptoms reported after Essure sterilization, methods of removal and results.

MATERIAL AND METHODS

Retrospective and single-centre cohort (Regional university hospital of Lille, France) was conducted. All women, having consulted from December 2016 to February 2019 for symptoms related to Essure insertion, were included. All the symptoms were noted. A second group was created that included patients who underwent Essure removal to evaluate the benefits of surgery on these symptoms.

RESULTS

The study included 98 patients. Most frequent symptoms were musculoskeletal pain (75 %), asthenia (63 %) and pelvic pain (55 %). Fifty-nine patients (60 %) underwent surgery. Surgery appeared beneficial with reduction of symptoms in 60 % of these patients, complete resolution in 33 % and no reduction of symptoms in 7%. Many symptoms were relieved by surgery with an overall decline of 96 % in menorrhagia, 94 % in metrorrhagia and 93 % in dyspareunia. However, other symptoms were not relieved by surgery like 100 % of sleep disorders, 70 % of abdominal pain cases and 57 % of memory impairment cases.

CONCLUSION

Symptoms related to Essure insertion are numerous. Although surgery appears beneficial, some adverse effects remain. Therefore, a preoperative aetiologic assessment and information about risk of surgery failure are important.

Quality of life after laparoscopic removal of Essure® sterilization devices

OBJECTIVES

To assess changes in quality of life after laparoscopic removal of Essure® sterilization devices (Bayer AG, Leverkusen, Germany).

STUDY DESIGN

In this prospective observational study in an academic research hospital, 80 women with new or worsening symptoms since placement of Essure® sterilization devices undergoing subsequent surgical removal were included. Laparoscopic removal of Essure® devices and salpingectomy with or without cornual excision were performed. Concomitant uterine procedures could be associated where indicated for gynaecological complaints. Comparison using the T student test for coupled series was done in this before-and-after study.

RESULTS

Health related quality of life (HRQL) was the primary outcome measured by the Short Form 12 (SF-12) questionnaire and a global 10 cm visual analogue scale (VAS). Secondary outcomes included assessment of pain, using continuous (VAS) and ordinal scales (Modified McGill Pain Questionnaire), menstrual bleeding (pictorial blood loss assessment chart (PBAC) score) and surgical feasibility and safety. There was a significant improvement in quality of life in both mental and physical health aspects of the SF-12 (34.02 (+/-1.19) vs. 49.61 (+/-1.42, P < .0001) and 36.55 (+/-0.99) vs. 43.32 (+/-1.18, P < .0001 respectively) as well as global VAS assessment (+2.91 (SD +/-0.27)) at the end of the first post-operative month. These improvements were maintained at three and six months. Mean pain decreased at one month following surgery compared to baseline (VAS 3.6 (+/-0.36) to 1.4 (+/-0.25), P < .0001 and McGill pain score 18.70 (+/-1.88) to 4.73 (+/-0.90), P < .0001). Improvements of a similar magnitude were observed when analysis was restricted to the 47 women without concomitant uterine surgery. No significant changes in bleeding were seen following of Essure® device removal. Planned procedures were all successfully completed.

CONCLUSION

Laparoscopic removal of Essure® devices in symptomatic women is technically successful and associated with short and medium-term improvement in quality of life as well as reduction in pelvic pain.

Design, Manufacture, and In vivo Testing of a Tissue Scaffold for Permanent Female Sterilization by Tubal Occlusion

Current FDA-approved permanent female sterilization procedures are invasive and/or require the implantation of non-biodegradable materials. These techniques pose risks and complications, such as device migration, fracture, and tubal perforation. We propose a safe, non-invasive biodegradable tissue scaffold to effectively occlude the Fallopian tubes within 30 days of implantation. Specifically, the Fallopian tubes are mechanically de-epithelialized, and a tissue scaffold is placed into each tube. It is anticipated that this procedure can be performed in less than 30 minutes by an experienced obstetrics and gynaecology practitioner. Advantages of this method include the use of a fully bio-resorbable polymer, low costs, lower risks, and the lack of general anaesthesia. The scaffold devices are freeze-cast allowing for the custom-design of structural, mechanical, and chemical cues through material composition, processing parameters, and functionalization. The performance of the biomaterial and de-epithelialization procedure was tested in an in vivo rat uterine horn model. The scaffold response and tissue-biomaterial interactions were characterized microscopically post-implantation. Overall, the study resulted in the successful fabrication of resilient, easy-to-handle devices with an anisotropic scaffold architecture that encouraged rapid bio-integration through notable angiogenesis, cell infiltration, and native collagen deposition. Successful tubal occlusion was demonstrated at 30 days, revealing the great promise of a sterilization biomaterial.

Current techniques and outcomes in hysteroscopic sterilization: current evidence, considerations, and complications with hysteroscopic sterilization micro inserts

PURPOSE OF REVIEW

To describe the current data regarding effectiveness, complications, postoperative evaluation, and surgical interventions associated with Essure hysteroscopic sterilization.

RECENT FINDINGS

Hysteroscopic sterilization is a commonly performed procedure that is offered as a well tolerated, effective, outpatient method of permanent sterilization. Over the past several years, concerns have been raised regarding correct placement and postoperative complications. This has led to statements by both the Food and Drug Administration (FDA) in October, 2016 and American Association of Gynecologic Laparoscopists in February, 2017, as a significant portion of women seek removal of these devices. A current black-box warning issued by the FDA in 2016 recommends discussion of 'the probabilities of rates or events' of adverse outcomes associated with Essure placement.

SUMMARY

Although hysteroscopic sterilization is usually a safe, effective option for permanent contraception, new evidence regarding complications has emphasized the need for proper education and counseling. Appropriate patient selection and knowledge of potential complications is paramount to ensuring patients, and medical providers are well informed and have realistic expectations regarding potential placement and postoperative issues.

Analysis of surgeries performed after hysteroscopic sterilization as tabulated from 3,803 Essure patient experiences

Objective

Although previous research has suggested that risk for reoperation among hysteroscopic sterilization (HS) patients is more than ten times higher than for patients undergoing standard laparoscopic tubal ligation, little has been reported about these subsequent procedures.

Methods

This descriptive cohort study used a confidential online questionnaire to gather data from women (n=3,803) who volunteered information on HS followed by device removal surgery performed due to new symptoms developing after Essure placement.

Results

In this sample, mean age was 35.6 years and women undergoing hysterectomy after HS comprised 64.9% (n=2,468). Median interval between HS and hysterectomy was 3.7 (interquartile range, 3.9) years and mean age at hysterectomy was 36.3 years. Some patients (n=1,035) sought removal of HS devices and fallopian tubes only, while other miscellaneous gynecological procedures were also occasionally performed for Essure-associated symptoms. When data from all patients who had any post-Essure surgery besides hysterectomy were aggregated (e.g., device removal + “other” cases, n=1,335) and compared to those cases undergoing hysterectomy, mean age was significantly lower than for the hysterectomy group (34.4 vs. 36.3 years, respectively; P<0.01); uterus-conserving surgeries were also typically performed significantly earlier than hysterectomy (P<0.01).

Conclusion

This investigation is the first to characterize specific gynecological operations after Essure, and suggests that the predominant surgical answer to HS complaints is hysterectomy for many women. Dissatisfaction with HS may represent an important indication for hysterectomy and additional study is needed to quantify this phenomenon.

Minimally Invasive Gynecologic Surgery for Benign Conditions: Progress and Challenges

OBJECTIVE

The objective of this review is to evaluate the progress made in laparoscopic and hysteroscopic gynecologic surgery and address challenges still faced by surgeons using minimally invasive techniques to improve the care of women with noncancerous gynecologic problems.

METHODS

Relevant literature was reviewed and evidence-based arguments put forward in the article for the progress that has been made and the deficiencies that still exist.

RESULTS

In the last 2 decades, enormous progress has been made in providing minimally invasive surgical options for women with gynecologic diseases. The progress has been especially striking in the performance of hysterectomy, the most common major surgery performed on nonpregnant women. The recent controversy over power morcellation has revealed a poor understanding of the literature concerning leiomyosarcoma leading to confusion and consequently denial of minimally invasive surgical options for many women. Hysteroscopic surgery has been evolving rapidly with the development of hysteroscopic morcellator, global endometrial ablation systems, and hysteroscopic tubal sterilization.

CONCLUSIONS

Although huge advances have been made in minimally invasive gynecologic surgery, high-quality evidence from well-designed clinical trials is lacking for many of the new technologies. Accurate estimates regarding the risk of occult leiomyosarcoma are also lacking. Additional research is urgently needed to address these deficiencies.

Referrals for complications following hysteroscopic sterilisation: characteristics associated with symptomatic patients after the Essure procedure

OBJECTIVE

This report summarises recent experience with a series of symptomatic Essure® patients with an emphasis on clinical presentation, preoperative imaging, surgical intervention, and outcome.

METHODS

This case series presents Essure® patients (n = 7) who sought medical consultation for various complications. This retrospective analysis is based on consultations during a six-month interval beginning in April 2015.

RESULTS

In this sample, mean (± SD) patient age was 35.9 ± 3.4 yrs. The gravida/parity status was 3.6 ± 1.1 and 2.4 ± 1.4, respectively. Average duration of exposure to Essure® coils among these patients was 25.6 ± 24.5 (range 5-67) months. Except for one woman, these patients had hysteroscopic sterilisation (HS) either with heavy sedation or under general anaesthesia. More than two Essure® devices were implanted in two women. Complications reported after HS included device migration, coil fragmentation, tissue perforation, and vaginal expulsion of Essure® fragment. Three of seven women have required hysterectomy.

CONCLUSION

The current series offers evidence of migration of contraceptive coils as well as Essure® inserts perforating tissue and being spontaneously expelled. Evaluation of symptomatic HS patients should include determining how many devices have been implanted, as some women have more than two.

Endometrial fluid associated with Essure implants placed before in vitro fertilization: Considerations for patient counseling and surgical management

Essure (Bayer) received approval from the U.S. Food and Drugs Administration as a permanent non-hormonal contraceptive implant in November 2002. While the use of Essure in the management of hydrosalpinx prior to in vitro fertilization (IVF) remains off-label, it has been used specifically for this purpose since at least 2007. Although most published reports on Essure placement before IVF have been reassuring, clinical experience remains limited, and no randomized studies have demonstrated the safety or efficacy of Essure in this context. In fact, no published guidelines deal with patient selection or counseling regarding the Essure procedure specifically in the context of IVF. Although Essure is an irreversible birth control option, some patients request the surgical removal of the implants for various reasons. While these patients could eventually undergo hysterectomy, at present no standardized technique exists for simple Essure removal with conservation of the uterus. This article emphasizes new aspects of the Essure procedure, as we describe the first known association between the placement of Essure implants and the subsequent development of fluid within the uterine cavity, which resolved after the surgical removal of both devices.

Early hysteroscopic removal of intratubal microinserts with urologic stone retrieval forceps

BACKGROUND

Nickel hypersensitivity reactions can be an indication for the removal of intratubal microinserts used for hysteroscopic sterilization. Although early removal can be attempted hysteroscopically, hysteroscopic grasping forceps may be inadequate to grasp deeply positioned inserts.

CASE

Three days after hysteroscopic sterilization, the patient presented with a rash consistent with a nickel hypersensitivity reaction. Ten days after placement, we successfully performed hysteroscopic removal of an intratubal microinsert with tri-prong urologic stone retrieval forceps after standard hysteroscopic grasping forceps was unable to reach the deeply positioned device. Within 36 hours of bilateral microinsert removal, all symptoms resolved.

CONCLUSION

In difficult cases, 1-mm tri-prong urologic stone retrieval forceps can be useful for early hysteroscopic removal of intratubal microinserts.