HYSTEROSCOPIC ENDOMETRIAL ABLATION

Acute Severe Hyponatremia following Hysteroscopic Procedure in a Young Patient: A Case Report and Review of the Literature

Background

Hysteroscopic surgery is a minimally invasive procedure used to diagnose and treat intrauterine pathologies. It requires distension of the uterine cavity for the adequate visualization of the operative field. Glycine (1.5%) is one of the most commonly used solutions because it is nonconductive and also has good optical properties. However, acute hyponatremia is a critical complication that can develop after the absorption of a sufficient amount of the irrigation medium. Case Presentation. We report a case of a 43-year-old female patient who developed acute symptomatic hyponatremia (104 mEq/L) and pulmonary edema secondary to hysteroscopic resection of leiomyoma and hastily approached with rapid sodium correction measures.

Conclusion

Multiple strategies can be taken to reduce the risk of fluid absorption and subsequent hyponatremia. Moreover, attention should be paid to the treatment approach for patients with acute hyponatremia following hysteroscopic procedures; rapid correction of acute hyponatremia for such patients might be safe, although there is no consensus in the literature, and further trials are needed.

Outcome of the first 220 cases of endometrial balloon ablation using Cavaterm™plus

The objective of this prospective study was to evaluate the effectiveness of day-case Cavaterm plus thermal balloon endometrial ablation in the treatment of therapy-resistant menorrhagia. The study included 220 patients with a mean age of 41 years, mean parity of 2.1 and mean duration of menorrhagia of 3.2 years. A 6-mm diameter Cavaterm plus catheter with a silicone balloon at its tip was used. The ablation time was 10 minutes at a temperature of 78 degrees C. No procedure-related operative or immediate postoperative complications were encountered. The mean follow-up period was 19 months (range 6-24 months). The amenorrhoea-hypomenorrhoea rates at the various follow-up periods ranged between 74% and 83%. At the end of follow-up, 83% of patients were satisfied with the procedure. We conclude that Cavaterm plus is a safe and effective treatment for menorrhagia and has good patient acceptability.

Decreasing utilization of hysterectomy: a population-based study in Olmsted County, Minnesota, 1965-2002

OBJECTIVE

The purpose of this study was to assess temporal trends for hysterectomy among Olmsted County, Minnesota women.

STUDY DESIGN

Using the Rochester Epidemiology Project database, we identified all county residents undergoing a hysterectomy in 1965-2002. Temporal changes in the utilization (incidence) rate, type, diagnostic indications, and age at surgery were assessed.

RESULTS

Between 1965 and 2002, 6152 women had a hysterectomy alone, whereas 3126 women had, in addition, a pelvic floor repair; the age-adjusted utilization rate for hysterectomy alone and for combined procedures declined (P < .0001) by 13% and 63%, respectively. Except for subjects aged 75-85 years, this decline affected every age group. The distribution of vaginal (56%) and abdominal (44%) procedures differed across indications. Uterine leiomyomata, precancerous conditions, and genital prolapse accounted for 28%, 23%, and 12% of all procedures, respectively.

CONCLUSION

Among community women, the utilization rate, age distribution, and indications for a hysterectomy changed substantially between 1965 and 2002.

Hysteroscopic endometrial ablation using free heated saline for the treatment of menorrhagia

STUDY OBJECTIVE

To assess the safety and efficacy of hysteroscopic endometrial ablation using controlled intrauterine instillation and circulation of heated (90 degrees C) saline.

DESIGN

Phase II clinical study (Canadian Task Force classification II-2).

SETTING

Preliminary study performed in an outpatient ambulatory surgery center of a university hospital.

PATIENTS

Twenty women with menorrhagia of benign causes.

INTERVENTION

Hysteroscopic endometrial ablation.

MEASUREMENTS AND MAIN RESULTS

There were no complications. At no time did fluid leak from the fallopian tubes or cervix during treatment. Six patients had concurrent laparoscopy to measure serosal temperatures and to observe fimbriae directly during the 10-minute treatment. Serosal and endocervical temperatures were not elevated. Eighteen women kept evaluable menstrual diaries for 2 months before and 12 months after surgery. Ten women (55.6%) became amenorrheic, four (22.1%) hypomenorrheic, and three (16.7%) returned to normal periods after 12 months of follow-up. One woman (5.6%) reported a 75% decrease in menstrual flow but continued to be menorrhagic by definition. One patient subsequently underwent hysterectomy for simple endometrial hyperplasia.

CONCLUSION

This procedure appears to be a safe method of globally ablating the endometrium, resulting in effective treatment of menorrhagia.

Initial experience with a physiologic morcellating resectoscope

A new physiologic morcellating resectoscope allows operative hysteroscopy to be performed with a physiologic distention medium, thus reducing the risk of dilutional hyponatremia and cerebral edema secondary to excessive absorption of nonphysiologic fluid. To study this new technology, we gathered in vitro data with the SL resectoscope with dual-function electrode (FemRx, Sunnyvale, CA). Coupled to a standard monopolar electrosurgery unit and operating in normal saline or Ringer's lactate solution, extirpated uteri showed equivalent depth of tissue necrosis with this new physiologic morcellating resectoscope as with a conventional monopolar resectoscope used in an electrically nonconductive fluid.

Measurement of serosal temperatures and depth of thermal injury generated by thermal balloon endometrial ablation in ex vivo and in vivo models

OBJECTIVE

To evaluate the safety profile of endometrial ablation performed with a thermal balloon as defined by serosal temperature elevation and depth of injury.

DESIGN

Observational study with histopathologic correlation conducted in ex vivo and in vivo phases.

SETTING

Academic medical center.

PATIENT(S)

Twenty patients undergoing total abdominal hysterectomy.

INTERVENTION(S)

Endometrial ablation with a thermal balloon.

MAIN OUTCOME MEASURE(S)

Serosal temperature elevation and histologic depth of injury.

RESULT(S)

Ex vivo phase results revealed serosal temperatures remained within a safe physiologic range (<45 degrees C). Greatest depth of myometrial injury in the premenopausal uteri was 5.8 mm over the anterior lower uterine segment. In postmenopausal uterus. the greatest depth of myometrial injury was 3.8 mm in the anterior midline. In vivo phase results revealed mean (+/- SD) peak serosal temperatures of 36.1 +/- 1.6 degrees C. As with the ex vivo phase. histologic examination revealed deep endometrial and superficial myometrial damage to all areas. The greatest depth of myometrial injury occurred in the midfundus at 3.4 mm.

CONCLUSION(S)

No patients experienced complications or adverse events secondary to treatment. Results showed that transuterine thermal injury is a highly unlikely scenario. In both phases of this study, histologic examination revealed that temperatures exposed to the endometrial layer were sufficient to cause tissue damage.

Uterine thermal balloon therapy for the treatment of menorrhagia: the first 300 patients from a multi-centre study. International Collaborative Uterine Thermal Balloon Working Group

OBJECTIVE

To evaluate the safety and efficacy of thermal balloon therapy for menorrhagia.

DESIGN

Prospective, observational study.

SETTING

Fifteen centres in Canada and Europe.

POPULATION

Two hundred and ninety-six eligible women for whom follow up data were available for three months or more. Eligible women included those for whom further fertility was not a concern, were not postmenopausal, suffered from intractable menorrhagia, had a normal uterine cavity, and who were fully informed regarding the investigational nature of uterine thermal balloon therapy.

METHODS

Three hundred and twenty-one procedures of balloon endometrial ablation were performed using the same protocol between June 1994 and August 1996. Exclusion criteria included structural uterine abnormality or (pre) malignant lesions. Treatment entailed controlled heating of fluid in an intrauterine balloon. General anaesthesia was employed in the 61% of procedures while local anaesthesia with or without sedation was used in 39% of cases.

ANALYSIS

Follow up data at 3 and/or 6, and/or 12 months were required for inclusion in the analysis. A paired t test, Wilcoxon signed-ranks test, and multiple and logistic regression analyses were used to evaluate the changes in bleeding and dysmenorrhoea patterns, and possible confounding variables, respectively. Success was defined as the subjective reduction of menses to eumenorrhoea or less.

RESULTS

No intra-operative complications occurred, and post-operative morbidity was minimal. Success of the procedure was constant over the year (range 88%-91%). Treatment led to a significant decrease in the duration of menstrual flow and severity of pain (P < 0.0001). Increasing age, higher balloon pressure, smaller uterine cavity, and a lesser degree of pre-procedure menorrhagia were associated with significantly improved results. Pre-treatment with gonadotrophin releasing hormone agonists increased amenorrhoea and spotting rates (P = 0.03), but was only used in 5% of cases.

CONCLUSION

Thermal balloon endometrial ablation appears to be safe, as well as effective in properly selected women with menorrhagia and is potentially an outpatient procedure.

Clinical trial of the uterine thermal balloon for treatment of menorrhagia

STUDY OBJECTIVES

To evaluate the safety and efficacy of thermal balloon endometrial ablation in women with menorrhagia, and to identify factors influencing outcome.

DESIGN

Prospective, observational study (Canadian Task Force classification II-2).

SETTING

Three Canadian university-affiliated teaching hospitals.

PATIENTS

One hundred twenty-one women suffering from menorrhagia serious enough to make them candidates for endometrial ablation or hysterectomy. Patients without obvious structural or (pre)malignant abnormalities were included if their uterine cavities sounded to less than 12 cm, they were in good health, and had undergone hysteroscopy or pelvic ultrasound and endometrial biopsy within 6 months and had a normal Papanicolaou smear within 1 year.

INTERVENTIONS

A balloon catheter was placed through the cervix and after inflation in the endometrial cavity with 5% dextrose in water, was heated to 87 +/- 5 degrees C. Two-thirds of patients avoided general anesthesia and very few required cervical dilatation to admit the 4.5-mm diameter catheter. Balloon pressures were 90 to 140 mm Hg in 13 patients; pressures between 140 and 190 mm Hg were well tolerated by the rest. Nineteen women underwent 12 minutes of therapy, and the rest had 8-minute sessions.

MEASUREMENTS AND MAIN RESULTS

No intraoperative complications occurred, and minor postoperative morbidity occurred in 4% of patients. Preoperative and postoperative bleeding was assessed by pad counts and patient self-reports. The degree of dysmenorrhea was recorded similarly. A paired t test was used to compare pretreatment with posttreatment pad counts. A Wilcoxon signed rank test was employed to evaluate the effect of treatment on dysmenorrhea. The effects on outcome of several independent variables were analyzed by multiple and logistic regression. Success of the procedure was constant over the year (range 86-90%). Treatment led to significant decreases in menstrual flow, duration, and pain (p <0.0001). No significant effects of parity, uterine position or cavity depth, timing, or various endometrial-thinning regimens were found. Increasing age was significantly associated with increased odds of success (p < 0.05). Excluding the 19 women who underwent 12 minutes of therapy did not change statistical results, whereas excluding the 13 treated with balloon pressures less than 140 mm Hg improved the results. Conclusion. The facts that bleeding and dysmenorrhea were significantly reduced by thermal balloon endometrial ablation, that no intraoperative complication occurred, and that postoperative morbidity was minimal, lead us to conclude that this is potentially a safe and effective technique. Larger studies and longer follow-up are required to substantiate this impression.

Administration of medroxyprogesterone acetate after endomyometrial resection

STUDY OBJECTIVE

To assess the efficacy of endometrial resection for treatment of menorrhagia in women to whom no preoperative agent was given to prepare the endometrium.

DESIGN

Retrospective analysis of patients' records for all endometrial resections in which medroxyprogesterone acetate was used postoperatively.

SETTING

Hospital day surgery unit.

PATIENTS

Seventy patients with menorrhagia.

INTERVENTIONS

The women underwent transvaginal sonography, followed by hysteroscopy and endometrial biopsy. The endometrium was removed using the 27F resectoscope followed by coagulation with the rollerball. Medroxy-progesterone acetate was prescribed for 2 months after surgery.

MEASUREMENTS AND MAIN RESULTS

All women achieved a reduction in menstrual flow and 50% reported amenorrhea after endometrial resection. In only two was hysterectomy necessary due to recurrence of menorrhagia.

CONCLUSION

Preoperative endometrial preparation was unnecessary when endometrial resection was carried out for treatment of menorrhagia. However, the patients received medroxyprogesterone acetate postoperatively.