Thermoregulated radiofrequency endometrial ablation

OBJECTIVE

To test the hypothesis that treating dysfunctional uterine bleeding by automated application of electrothermal energy to the uterine cavity, with precise regional control, might yield results equivalent to those reported for hysteroscopically directed laser and electrosurgical endometrial ablations.

MATERIALS AND METHODS

Patients with life style compromising menorrhagia, referred to six gynecologic surgical centers for hysterectomy or endometrial ablation, were admitted to the study if they had normal cervical cytology, a benign endometrial biopsy, no defined cause for their bleeding, and consented to participate in the evaluation of a newly developed Vesta DUB Treatment System. The device consists of a silicone-inflatable electrode carrier to be inserted into the uterine cavity and a controller to monitor and distribute current from a matched electrosurgical generator. Treatment involved a 3-minute or shorter warm-up period and a 4-minute treatment phase.

RESULTS

Three- to 24-month follow-up data were available for 187 patients, with a mean follow-up of 14.8 months. The amenorrhea rate was 38%. Bleeding was reduced in 95% of patients. Actuarially, 88 +/- 3% of patients should expect to be free of menorrhagia, dissatisfaction, or need for a second procedure out to 24 months.

CONCLUSIONS

The unique regional feed-back control offered by this system causes thorough, evenly distributed, thermal destruction 4-5 mm into the myometrium that reduces bleeding with durability equivalent to published reports of hysteroscopic endometrial ablation.

Endometrial Ablation with the VestaBlate System in Mexico

The VestaBlate system will enable gynecologists to perform endometrial ablation in the office. It consists of a distensible balloon containing a surface array of electrodes, each with a temperature sensor. A computerized controller connects to an electrosurgical generator. The objective is to create tissue necrosis of adequate depth to destroy the functional endometrium without significant risk. The electrode balloon is inserted through the dilated cervix and inflated. Using 40 to 45 W, the electrode maintains a surface temperature of 70 to 75° C for 4 minutes. From January 1995 to November 1995 we performed endometrial ablation with local anesthesia and minimum sedation in 20 women, and assessed bleeding patterns 1 month before and 6 months after the procedure. Two patients (10%) failed the procedure, 4 (20%) had oligomenorrhea, and 14 (70%) had amenorrhea. Promising early results indicate that office-based endometrial ablation can be performed safely and effectively.

Laparoscopy versus Laparotomy for Radical Hysterectomy

From July 1993 to March 1996 we performed 62 radical hysterectomies, 15 (24.2%) by laparoscopy and 47 (75.8%) by laparotomy. All patients had cervical carcinoma FIGO stages Ia2 and Ib1. We compared the duration of surgery, blood loss, number of pelvic nodes obtained, surgical margins, and complications. The average duration of laparoscopic surgery was 4.5 hours versus 3 hours for laparotomy. Blood loss at laparoscopy was 250 ml, and 600 ml at laparotomy. The number of pelvic nodes obtained by laparotomy was 24.74 and by laparoscopy an average of 25. In all cases the surgical margins were free of tumors. Two complications in the laparoscopy group were a vaginal hematoma and a ureteral injury. At laparotomy one ureteral fistula occurred. No difference between approaches in pathology specimens were seen. Blood loss was lower at laparoscopy but the duration of surgery was longer. Radical hysterectomy by laparoscopy seems safe and effective.

Endometrial ablation using a distensible multielectrode balloon

The VestaBlate system uses a multielectrode intrauterine balloon as a device to create effective and safe endometrial ablation (EA). The surface of the distensible balloon is impregnated with thermistors and thin, platelike electrodes. It is designed to deliver low-power electroenergy to the endometrium. Unlike the resectoscope techniques that require nonelectrolytic fluids for uterine distention, moving electrodes at high power outputs, and other variables that are operator dependent, the VestaBlate is computer controlled using a standard type electrosurgical generator. A respiratory enzyme stain, nitroblue tetrazoleum, was used to determine the extent and depth of tissue necrosis to a myometrial depth of 2 to 4 mm with uniform destruction of tissue with power setting at 45 W for a 4-minute application of energy. Sixty-nine patients have been treated, with 45 followed for at least 3 to 9 months. The amenorrhea rate is 40%; the oligomenorhea-hypomenorrhea rate is 49%.