Hysteroscopic endometial resection

A. Prof. Dr. Aisha Mohamed El-Bareg MBBS, DGO, MMedSci (ART), ABOG, (MD), PhD(UK)

Consultant Obstetrician & Gynecologist/subspecialty in

Endoscopic Surgery and Reproductive medicine

Al-Amal Hospital for Obs &Gyne. Infertility Treatments

and Genetic Research

Faculty of Medicine , Misurata University/Libya

Endometrial Ablation Destruction of Endometrium

Removal of the basal endometrium

By

Freeze, fry, roast, boil, broil,

vaporize

Abnormal uterine bleeding (AUB)

Any deviation from normal frequency, duration

or amount of menstruation in women of

reproductive age. NORMAL MENSES

•Frequency: 21-35 d

•Duration: 3-7 d

•Volume: 30-80 ml

AUB- Clinical types

•Polymenorrhoea: frequent (<21 d) menstruation,

at regular intervals

•Menorrhagia: Excessive (>80 ml) & / or prolonged

menstruation, at regular intervals

•Metrorrhagia: Mensturation at irregular intervals.

AUB- Clinical types

•Menometrorrhagia: both.

•Intermenstual bleeding: episodes of uterine

bleeding between regular menstruations.

•Hypomenorrhoea: scanty menstruation.

•Oligomenorrhea: infrequent menstruation (>35 d)

AUB- Causes

Organic cause

1. Pregnancy complications:

•Miscarriages

•Ectopic pregnancy

•Trophoblastic disease

AUB- Causes

2. Genital disease

. Tumors:

Benign- Fibroid, cervical & endometrial polyp.

Malignant:- Cervical, endometrial Ca.

- Ovarian (estrogen secreting) tumor.

. Infection: - PID

. Endometriosis, Adenomyosis

. IUCD

. Marked uterovaginal prolapse

AUB- Causes

Systemic cause:

. Endocrine: - Hypo & hyperthyroidism, DM

- Adrenal gland disease

- Hyperprolactinemia

. Coagulopathy:

•Idiopathic thrombocytopenic purpura,

•Von-Willebrand disease, Liver failure.

AUB- Causes

• Chronic systemic disease: anemia,

heart failure, liver failure

• Iatrogenic: Hormonal contraception, HRT,

anticoagulants, antipsychotic drugs.

• Emotional • Under & over weight

AUB- Causes

•Definition: Abnormal uterine bleeding in absence of

obvious pelvic organ disease or a

systemic disorder

•Incidence: • 60 % of AUB

Dysfunctional uterine bleeding (DUB)

Treatment options for DUB

• The only option for menorrhagia earlier was

dilation & curettage or hysterectomy.

• For gynaecologists, the hysterectomy is the

operative procedure demanding the highest

standard of skill and represents the pinnacle

of his surgical dexterity .

• For the patient, the operation symbolizes the

disintegration of her womanhood.

Hysterectomy creates

Iatrogenic psychoreactive problems.

Disturbances of bladder & rectum function.

Reduced sexual performance because of

excision of paravaginal and paracervical

network of nerves and ligation of uterine artery.

boon for feminity A

With advancement in technology, minimally invasive techniques has emerged as a boon with 2 fold benefits.

Get rid of excessive bleeding.

Uterus & ovaries remain intact to maintain feminity.

Unfortunately, still many young women undergo surgery in the form of hysterectomy.

Why not minimum invasive technique ?

Lack of expertise for MIS.

lack of facilities.

Inadequate counselling by doctors.

Misguidance by quacks and family

members.

Repeated visits to clinics.

Lack of knowledge, transport in under

developed rural areas.

With explosion of information

Women are asking “why their uterus is being

removed?”

Hysterectomy is perhaps the excessive

surgery for menorrhagia where only

endometrium is the culprit and not the uterus.

Abnormal uterine bleeding

Affects approximately 10-30% of premenop-

ausal women and up to 50% of perimenopausal

women.

It is a common reason for outpatient

gynecologic visits and is one of the most

common causes for surgery among women.

App. 600.000 hysterectomies are performed

each year in the U.S.

Abnormal uterine bleeding is reported as the

primary indication in 20% of patient.

With advent of endometrial ablation, 120,000

women annually has a less invasive alternative

to hysterectomy.

Abnormal uterine bleeding

Although the first medical literature reports of

endometrial destructive procedures are older

than 100 years, widespread adoption of this

modality did not occur until the advent of

hysteroscopically guided techniques.

Until the mid-1990s, hysteroscopically guided

ablation (Resectoscopic endometrial ablation)

using laser, fulguration, or vaporization

techniques was the most common approach.

Endometrial ablation

Endometrial ablation is primarily designed for

the treatment of abnormal or dysfunctional

uterine bleeding (AUB/DUB).

The goal of endometrial ablation is destruction

of the basal layer of the endometrium resulting

in decreased bleeding or even amenorrhea.


The endometrium should be destroyed to the

basilis level which is approximately 4–6 mm

deep.

Approximately 90% of patients will be

successfully treated with endometrial ablation.

The majority of these patients will experience

decreased bleeding ranging from normal to

light cycles.

However, anywhere from 15–60% will develop

amenorrhea depending on the endometrial

technique employed.


Advantages of endometrial ablation

compared to hysterectomy

Shorter time (30 min).

Can be done under local anesthesia- cervical

block +/- sedation which also allow office

setting.

Day case procedure, no hospital stay.

Lower cost.

Lower morbidity, Back to regular activities next

day.

Aim & action of ablation

AIM – To destroy the visible endometrium

including the cornual endometrium .

ACTION:

Heat penetrates 3-5 mm deeper, burns the

superficial myometrium and coagulates the

radial branches uterine plexus.

No regeneration due to loss of basal and spiral

arterioles. 6-8 weeks later the uterine walls

scars and shrinks.

Endometrial Ablation – indications

(inclusion criteria)

Abnormal uterine bleeding of benign etiology

not responding to medical therapy.

No desire for future fertility.

High risk for surgery (hysterectomy) but desire

to retain the uterus.

Absolute CI:

Pregnancy or desire to future pregnancy

Active urogenital or pelvic infection

Suspected or documented premalignant or

malignant condition of the uterus

Endometrial Ablation – contraindications

(Exclusion criteria)

Others:

• Large uterine cavity > 12 cm, hydrosalpinx

• History of classical cesarean section

• History of a transmural myomectomy

• Uterine anomalies

Preoperative patient counselling

Adequate preoperative counseling

Hypomenorrhea. Amenorrhea

Rare need for hysterectomy

Not a method of contraception

No protection - endometrial Ca.

Failure of procedures - 2nd intervention

Pre-operative workup

The preoperative workup should give a

complete diagnosis of the interactivity pathology

(submucous leiomyoma, polyp) or myometrial

pathology (interstitial fibroid, adenomyosis) that

can account for the abnormal bleeding.

It should also ensure that there is no suspicious

lesion.

CBC, coagulation profile, s. electrolytes.

TVS: detailed uterine contour, pathology.

Diagnostic hysteroscopy with biopsy of

endometrium.

Patient written consent.

Endometrial preparation:

Reduces operation time

Increases efficacy of the procedure

Decreases the possibility of fluid overload.

Pre-operative workup

Endometrial preparation

A preoperative treatment of GnRh agonists

can be administrated to prepare (thinning) the

endometrium.

Progesterone can also be used.

Some authors recommend curettage or

aspiration of the endometrium before surgery

if was not possible to submit the patient to an

appropriate pharmacological therapy.

Endometrial suppresion treatment course is

useful even in the postoperative phase.

Endometrial preparation

Cervical preparation

Misoprostol – PGE1 analogue

200-400 mcg PO/PV, 4-6 hrs before surgery.

Intracervical vasopressin

(10 units in 50 mL saline) injected as 3 or 4 mL

into the stroma of the cervix which causes

intense myometrial and arterial wall contractions

for 20–30 minutes.

Significant reduction in force of cx. Dilation.

Decrease risk for absorption syndrome,

bleeding.

Failure of endometrial ablation

Adenomyosis

Bulky uterus: >12mm

Curettage, immediately prior to ablation.

No preoperative endometrial suppression.

I.Hysteroscopic:

1. Electrosurgical

a.Roller ball vaporization

b.Wire loop resection

2. Laser II.Non-hysteroscopic:


Tips for endometrial ablation

Essentially the entire endometrium must be

ablated, small foci of endometrial remnant may

give rise to extensive re-epitheliazation.

The entire endometrial thickness must be

ablated. However, to prevent immediate

complications and induce scarring, ablation

should not be carried too deep into the

myometrium.

Normally, the isthmic epithelium is spared to

prevent cervical stenosis and adhesion.

1. Internal longitudinal

layer

2. External circular layer

a. Functional

endometrium

b. Venous plexus

The Endometrium

To determine the edges of the resection,

knowledge of the anatomy of the endometrium

is essential.

Ideally, patients are followed up by keeping

open option of inspecting the uterine cavity via

hysteroscopy.

Hysteroscopy-guided techniques are currently

considered superior to blind methods:

More effective.

Allow direct visualization of other lesion

which can be removed at the same time.

Permit histological evaluation of the sample

specimen

Tips for endometrial ablation

Cervical Resection -Trans

of the Endometrium

TCRE)(

election criteria for TCRES

Abnormal or excessive menstrual bleeding

justifying hysterectomy.

No relief from medical therapy or medical

treatment not tolerated or rejected.

Benign endometrial histology and pap smear.

Uterine size not more than10weeks pregnancy

or uterine cavity <10 -12cm.

Submucous fibroid of <6 cm in size.

Completed family.

Anaesthesia

Sedation.

Local anaesthesia with or without vasocon-

stricting agents.

Spinal or epidural anaesthesia:- as it gives less

bleeding, patient remains conscious and can

report of fluid overload.

Short general anaesthesia.

Operative Technique

Dilation of the cervix Bimanual examination is performed to

evaluate the position of the uterus before

dilation. This lowers the risk of perforation.

A speculum is inserted and the cervix is

grasped to bring the uterus into an

intermediary position.

The procedure routinely begins with a

diagnostic hysteroscopy if this was not done

during the preoperative evaluation.

The cervix is then dilated with Hegar’s

dilators, using progressively larger dilators

until a No. 10 dilator can be inserted.

Operative Technique

Inserting the Resectoscope:

The endo-camera, the resectoscope and the

electrode are then assembled and connected

to the Xenon light source, the electro-surgical

generator and the suction-irrigation tubing.

Care must be taken to remove all air bubbles

from the tubing. The resectoscope is then

introduced under videoscopic guidance.

Resection Technique

The resection is usually begun on the posterior

surface, creating a groove from the fundus of

the uterus to the isthmus with a regular,

continuous, flexing motion of the arm.

The initial groove is used to determine how

deep the resection must be.

Stopping on the muscular wall whose limits

are defined by the external circular fibers of

the myometrium, before the venous plexus

layer .

Classically, the resection of the endometrium

is completed in a clock wise direction, and

includes the posterior surface, the left edge,

the anterior surface and the right edge.

The margins of the isthmic portion of the

uterus must be preserved due to the proximity

of the uterine vessels,

The endocervical portion must not be

resected, to avoid endocervical adhesions that

can lead to pain, adhesion.

End of Procedure The hysteroscope is then removed and the

loop resection electrode is replaced by a

Rollerball coagulation electrode that rotates on

an axis to ensures a homogeneous

coagulation.

As the uterine wall is thinner at the level of the

ostia, and because of the difficulty involved in

resecting the fundus of the uterus, it may be

easier to begin the procedure by coagulating

the 2 ostis and the fundus of the uterus.

During the resection of the endometrium,

hemostasis is performed as needed with

elective coagulation of the vessels.

At the end of the procedure, irregularities of

the uterine wall must be eliminated..

The shavings of the endometrium are

collected for histologic examination using the

loop or blindly by forceps..

Preferably, the shavings are not removed as

they are resected, but pushed towards the

bottom of the cavity and removed at the end of

the procedure.

Advantages TCRE

Compared to other methods of ablation

Endometrial tissue for HP is provided.

Superficial resection of myometrium reduces

failure rates when adenomyosis is present.

Resection of polyp, septum, adhesions and

submucous myoma can be done at the same

sitting.

Disadvantages of TCER

Compared to other methods of ablation:

• Requires greater hysteroscopy skills

• Longer duration

• Extensive understanding of uterine anatomy.

Intraoperative complication

Cervical trauma, uterine perforation,

Intra peritoneal hemorrhage.

Thermal injury to adjacent structures.

Intra operative hemorrhage.

Fluid overload, hyponatremia, hypoosmolarity

& brain oedema

Air embolism.

Post operative complications

Short term

Infection

Haematometra

Secondary haemorrhage

Cyclical pain

Treatment failure

long term

Recurrence of symptoms.

Pregnancy.

Cancer.

Steps to avoid complications of TCER

• Preoperative GnRh analogs, progesterone,

injection of intracervical vasopressin.

• Use least pressure to maintain uterine

distension below mean arterial pressure of

patient.

• Strict adherence to a protocol for measurement

of systemic absorption.

• continuous monitoring of distension media

used by accurate of fluid deficit.

• Check s. electrolytes before, after procedure.

Non-hysteroscopic

Global Endometrial Ablation (GEA) Balloon ablation

Cavaterm thermal balloon ablation

Radio frequency probe

Unipolar electrodes

Bipolar electrodes

Microwave endometrial ablation (MEA).

Hydrothermal ablation (HTA) microsulis.

Diode laser photodynamic therapy.

Photodynamic therapy

Cryo surgery

Global Endometrial Ablation

• Non-hysteroscopic blind procedures

• Also called 2nd generation techniques.

• Advantages

• Easier to perform

• With less skill & training

• With local anaesthesia

• Disadvantages

• No material for HP examination

• Non-repeatable

Non-hysteroscopic

Global Endometrial Ablation (GEA)

Thermachoice balloon ablation

Cavaterm thermal balloon ablation

Radio frequency probe

Unipolar electrodes

Bipolar electrodes

Microwave endometrial ablation (MEA).

Hydrothermal ablation (HTA) microsulis.

Diode laser photodynamic therapy.

Photodynamic therapy

Cryo surgery

Indication

Young women with uterus of normal size and

heavy bleeding.

Can be offered to mentally disabled, bed

ridden, paralysis, medically unfit like too obese,

hypertensive, diabetes, renal failure, terminal

cancer patient

ThermaChoice Balloon Ablation

Contraindications

Pregnancy desired.

History of latex allergy.

Suspected endometrial cancer.

Existence of weak myometrium (c.s,

myomectomy).

Active genital or urinary tract infection.


The procedure can be done under local anaes-

thesia or sedation. As there is no necessity of

cervical dilation prior to insertion of the catheter,

short general anaesthesia can be used in

apprehensive patient.

step 1

An initial PV examination reveals the size of the

uterus.

Procedure


Step 2

a suction curettage is done to thin the endomet-

rium prior to the procedure.

Step 3

After holding the cervix, the catheter is primed &

inserted upto the fundus.

Step 4

Sterile 5 percent dextrose water is injected into

the balloon slowly until the intrauterine pressure

stabilizes between 160 and 180 mmHg.

Step 5

Endometrial tissue is thermally ablated by

maintaining temperature 87⁰C for 8 minutes.

Step 6

Fluid is drawn out and the deflated catheter is

withdrawn. For safety, the machine automatically

switches off if the pressure or temperature

fluctuates or is above preset values.

Post operative care & follow up

Cramping / pelvic pain – ranges from mild to

severe.

Nausea & vomiting.

Vaginal discharge – may be watery for 2 – 3

weeks.

Sexual intercourse to be avoided.

Regular pap smear to be continued.

Results

• 76% eumenorrhoea or hypomenorrhoea.

• success depends on.

• Age of patient.

• Duration of menorrhagia.

• Thickness of endometrium.

• if more than 4mm, then preoperative

medical preparation should be done.

conclusion

• Thermachoice balloon ablation is an effective

method and can reduce hysterectomy rate

thus reducing morbidity in women.

• Easy, No much skills required

Microwave Endometrial ablation (MEA)

• Developed and pioneered in the UK in the mid

1990’s.

• Received US FDA approval in 2003.

• Electromagnetic waves with a wave-length of

0.3-30cm.

• At a frequency of 9.2 GHz, and at a low power

of 30 W, microwave energy and effectively

ensures the 5–6 mm depth of necrosis, which

is required to completely destroy the basal

layer of the endometrium.

• The system computer screen provides the

surgeon with a proven temperature band

of 70– 80°C.

Endometrial cryo-ablation

Hydrothermal ablation

Novasure System

• Three dimensional, Fan shaped, expandable

Bipolar device.

• Porus metallic membrane draped around

metallic skeleton

• Power used 180w (radiofrequency)

• Treatment time (3min).

• Depth of destruction 4-4.5mm in uterine

corpus, at corneal region 2.2 – 2.9 mm.

• Satisfaction rate 83%.

Cavaterm Thermal Balloon Ablation

• Introduced in 1996

• Silicon balloon catheter attached with central

unit.

• 1.5% glycine fills the balloon

• fluid heated for 15 minutes

• 1-3yrs follow up showed 70% amenorrhea or

minimum bleeding.

• Cavaterm Procedure & novasure procedure

were found to be safe & effective.

Repeat endometrial ablation

Endometrial ablation by many methods will be

successful up to 90% of the time.

Women in whom the procedure is not

successful have the choice of hysterectomy,

observation, or repeat ablation.

Repeat ablation done after 6 months of the

initial one.

Yag laser or roller ball is used

Global ablation should not be used as the

repeat ablation should be performed under

direct vision.

Repeat endometrial ablation

Why repeat endometrial ablation???

1. Uterine bleeding improved, but still heavy or

prolonged and adversely affecting the patient’s

quality of life.

2. Physical or mental disability in which

amenorrhea is desired.

3. Initial procedure not completed because of

excess fluid absorption, leiomyomas, instrument

4. malfunction, or uterine perforation. 5. Amenorrhea desired by patient despite

achieving reduced or normal flow.

6. Unimproved.

conclusion

Evidence based studies and reviews reveal that:

TCRE is an excellent successful treatment and

a genuine alternative to hysterectomy.

Visual techniques are definitely superior to non

visual techniques of ablation.

Success rate reported as 79 – 95%.

YOU WILL REMEMBER

A LITTLE OF WHAT YOU HEAR,

SOME OF WHAT YOU READ,

CONSIDERABLY MORE OF WHAT

YOU SEE,

BUT

ALMOST ALL OF WHAT YOU

UNDERSTAND.

Hysteroscopic endometial resection

Health & Medicine

Transcript of Hysteroscopic endometial resection