Douglas R. Phillips

Experience with laparoscopic leiomyoma coagulation and concomitant operative hysteroscopy.

STUDY OBJECTIVES To evaluate the experiences of women who underwent laparoscopic leiomyoma coagulation (myolysis) alone and those who had myolysis in conjunction with transcervical endomyometrial resection (TEMR), transcervical electrosurgical resection of submucous leiomyomas (TSR), or both. DESIGN Continuing, prospective observational study with mean (+/- SEM) follow-up of 36.0 +/- 1.2 months (range 18-54 mo). SETTING Gynecology department of community and teaching hospitals. PATIENTS One hundred sixty-seven women with symptomatic leiomyomata. INTERVENTIONS Women complaining of pressure, pain, or both underwent only myolysis. Those with the additional symptom of chronic menorrhagia underwent TEMR, TSR, or both. Nineteen (11.4%) of the 167 women had elective second-look laparoscopy 6.0 +/- 0.3 months (range 6-8 mo) later to evaluate possible adhesion formation. MEASUREMENTS AND MAIN RESULTS Main outcome measures were control of symptoms, numbers and types of concomitant and subsequent procedures, changes in uterine and leiomyomata volumes, and number of successful pregnancies. Mean total uterine volume of the 167 women decreased from 620 +/- 28.4 cm3 before leuprolide treatment to 131 +/- 7.2 cm3 by 7 to 12 months postoperatively (p <0.0001). Five (3.6%) women had hysterectomies for persistent or recurrent menorrhagia, pain, pressure, or a combination of symptoms (p = 0.01). Pathologic evaluation revealed adenomyosis, leiomyomata, or both. Of 52 women with chronic menorrhagia, 33 (63.5%) developed amenorrhea and 17 (32.7%) developed hypomenorrhea or eumenorrhea; 2 (3.8%) required repeat TEMR. The two women who desired to retain fertility had uncomplicated full-term pregnancies and uneventful vaginal deliveries. CONCLUSIONS Myolysis alone or in conjunction with TEMR, TSR, or both obviated the need for major surgery in 162 (97.0%) women. Until further studies are concluded, myolysis should be performed selectively in women contemplating pregnancy.

The effect of dilute vasopressin solution on blood loss during operative hysteroscopy: A randomized controlled trial

Objective To assess the effect of intracervical injection of dilute (0.05 U/mL) vasopressin solution on blood loss during operative hysteroscopy. Methods In a randomized, double-blind study, dilute vasopressin solution or placebo (normal saline) was injected into the cervical stroma of 106 women before dilation of the cervix in preparation for operative hysteroscopy. Intraoperative bleeding was calculated by dividing the number of red blood cells per milliliter of outflow distention fluid by the number of red blood cells per milliliter of the womans blood immediately before the procedure and multiplying this quotient by the total amount of outflow fluid collected. Pressures were kept constant with a hysteroscopic infusion pump. Results The mean (± standard error of the mean) intraoperative blood loss of the treated (vasopressin) and control (placebo) groups was 20.3 ± 4.1 mL (range 0–135) and 33.4 ± 5.4 ml, (range 0–290), respectively. The volume of distention fluid intravasation in the treated and control groups was 448.5 ± 47.0 ml, (range 30–1410) and 819.1 ± 79.7 mL (range 20–1977), respectively. The operating time in the treated and control groups was 31.1 ± 1.2 minutes (range 18–52) and 34.1 ± 1.3 minutes (range 19–65), respectively. For all three outcome measures, the differences between the two groups were statistically significant, but for visual clarity of the uterine cavity during surgery, the difference was not significant. Conclusion Administration of dilute vasopressin solution (0.05 U/mL) to the cervical stroma significantly reduces blood loss, distention fluid intravasation, and operative time during hysteroscopy. Further evaluation is required to determine the optimum dosage.

Laparoscopic bipolar coagulation for the conservative treatment of adenomyomata

STUDY OBJECTIVE To assess the effectiveness of treating adenomyomata with laparoscopic bipolar coagulation. DESIGN Prospective, observational study. Setting. The gynecology department of a community hospital. PATIENTS Ten women, each with severe dysmenorrhea, chronic menorrhagia, and adenomyomata diagnosed by magnetic resonance imaging. INTERVENTIONS Laparoscopic bipolar coagulation of adenomyomata. MEASUREMENTS AND MAIN RESULTS The mean (+/- SEM) total adenomyoma volume before leuprolide acetate administration was 119 +/- 16 cm3 (range 6-190 cm3); after 3 months of therapy this was reduced to 86 +/- 8 cm3 (range 6-162 cm3, p <0. 0001) a 27.7% reduction. Further reduction occurred 7 to 12 months postoperatively to 31 +/- 3.4 cm3 (range 3-155 cm3, p <0.0001), a 73.9% reduction from baseline. Twelve months postoperatively, seven (70.0%, p <0.05) women had continued resolution or significant reduction of dysmenorrhea and resolution of menorrhagia. One woman (10.0%) with unresolved dysmenorrhea and menorrhagia required hysterectomy, and two (20.0%) with recurrent menorrhagia required resection of the endomyometrium; one continued to have menorrhagia but refused further surgical or medical treatment. CONCLUSIONS Conservative treatment obviated the need for major surgery in 90% of women with adenomyomata, but further evaluation of this technique is necessary to determine its definitive role.

Endometrial ablation for postmenopausal uterine bleeding induced by hormone replacement therapy.

STUDY OBJECTIVE To determine the effectiveness of transcervical endometrial ablation or endomyometrial resection for treating refractory postmenopausal uterine bleeding induced by hormone replacement therapy (HRT). DESIGN Prospective observational study. SETTING Community, teaching, and proprietary hospitals. PATIENTS Twenty-nine postmenopausal women experiencing troublesome uterine bleeding while taking hormones. INTERVENTIONS Hormone manipulation, office hysteroscopy or sonohysterography, endometrial curettage, and transcervical endometrial ablation or endomyometrial resection were performed in all 29 patients. MEASUREMENTS AND MAIN RESULTS Twenty-seven women (93.1%) who continued HRT became amenorrheic within 2 months of surgery. The two who did not have irregular, intermittent spotting, but neither one required or desired further surgical intervention. Five women discontinued HRT from 3 to 53 months postoperatively (mean 12.5 +/- 8.2 mo) because of apprehension about developing breast cancer and for personal reasons. The 24 (82.8%) who continued HRT were observed for as long as 99 months (mean 36.4 +/- 5.5 mo); 22 (91.6%) of them remained amenorrheic. Pathologic examination of tissue specimens revealed atrophic endometrium in 4 patients, adenomyosis in 7, simple hyperplasia in 4, submucous leiomyomas in 11, endometrial polyps in 4, and proliferative endometrium in 1. There were no perioperative complications. CONCLUSION Endometrial ablation or endomyometrial resection was an effective alternative to discontinuing HRT for these postmenopausal women whose uterine bleeding was unrelieved by modification of their sex steroid regimens.

Preventing hyponatremic encephalopathy: Comparison of serum sodium and osmolality during operative hysteroscopy with 5.0% mannitol and 1.5% glycine distention media

STUDY OBJECTIVE To determine whether isotonic 5.0% mannitol is superior to 1.5% glycine in preventing development of hyponatremic encephalopathy. DESIGN Prospective, comparative study (Canadian Task Force classification II=2). SETTING Gynecology department of a community hospital. PATIENTS One hundred twenty-two women undergoing operative hysteroscopy. INTERVENTIONS Eighteen blood serum chemical indicators analyzed preoperatively and postoperatively in 61 women undergoing operative hysteroscopy with 1. 5% glycine (group 1) were compared with those of 61 women having similar surgery with 5.0% mannitol (group 2). Fluid deficit (difference between input and output volume of distention fluid) was recorded, and differences between presurgical and postsurgical indicators of the two groups (mean difference score) were compared. MEASUREMENTS AND MAIN RESULTS Mean +/- SEM sodium difference scores of groups 1 and 2 were -1.73 +/- 0.42 mEq/L (range -7.00 to 2.00 mEq/L) and -5.04 +/- 1.07 mEq/L (range -36.00 to 3.00 mEq/L), respectively (p <0.01). Serum osmolality difference scores were -6. 88 +/- 1.36 mmol/L (range -13.00 to -1.00 mmol/L) and -1.87 +/- 0.35 mmol/L (range -3 to 15 mmol/L), respectively (p <0.01). Distention fluid deficits were 0.435 +/- 0.071 L (range 0-2.448 L) and 0.473 +/- 0.084 L (range 0-3.640 L), respectively (p = 0.862). Two women (3.4%) in group 1 and five (8.2%) in group 2 developed postoperative asymptomatic dilutional hyponatremia (p = 0.211), which was the only complication. Two of the five women in group 2 developed severe dilutional hyponatremia. CONCLUSION We found that 5.0% mannitol distention fluid produces greater postoperative dilutional hyponatremia than 1.5% glycine, but hypo-osmolality does not occur with mannitol. Its use should lessen the risk of hyponatremic encephalopathy.

A comparison of endometrial ablation using the Nd:YAG laser or electrosurgical techniques

STUDY OBJECTIVE To compare the results of endometrial ablations performed either with the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser or electrosurgically. STUDY DESIGN Retrospective study, with 4-year follow-up of 82 of 98 patients. SETTING Gynecology departments of teaching, community, and proprietary hospitals. PATIENTS One hundred sixty-six women requiring surgical treatment for menorrhagia between March 1986 and October 1992. INTERVENTIONS Fifty-eight women were treated with a Nd:YAG laser, 11 with a rollerball electrode, and 97 with a wire loop electrode. Concomitant resection of submucous leiomyomata was performed in 54 (32.5%) of the patients. MEASUREMENTS AND MAIN RESULTS The mean operating times, complication rates, mean volume of fluid absorption, concomitant surgery, morbidity, duration of hospital stay, and results of laser and electrosurgical endometrial ablations were similar. Thirty-nine women (69.9%) undergoing laser endometrial ablation became amenorrheic and 54 (96.4%) had satisfactory results after 6 months. Seven (63.3%) of the women who had a rollerball ablation became amenorrheic, and 10 (90.9%) had satisfactory results. Sixty-one women (70.9%) who underwent wire loop resection became amenorrheic, with 83 (96.5%) attaining satisfactory results. Four years postoperatively, 85.4% of the patients continued to have satisfactory results. CONCLUSIONS Laser and electrosurgical endometrial ablations are similarly effective treatment for patients suffering from chronic menorrhagia. This preliminary study should be followed by a randomized, controlled, prospective study to evaluate the two techniques more fully.

100 laparoscopic hysterectomies in private practice and visiting professorship programs

STUDY OBJECTIVE To evaluate 100 laparoscopic hysterectomies and their variations in private practice and visiting professorship programs. DESIGN A prospective observational study. SETTING Gynecology departments of 17 teaching, community, and proprietary hospitals in the northeastern United States. PATIENTS One hundred women who successfully underwent laparoscopic hysterectomy, 91 of whom were followed for 6 months. INTERVENTIONS From July 1990 to August 1994, 108 women (mean age 41.6 yrs, range 38-68 yrs) for whom a vaginal hysterectomy was relatively contraindicated underwent a hysterectomy attempted by the laparoscopic route. The most common indications for hysterectomy were pelvic pain, chronic menorrhagia, and uterine leiomyomas. The women were classified according to hysterectomy, with groups comparable in age, weight, uterine size and weight, concomitant surgery performed, uterine and coexisting pathology, and history of pelvic surgery. Of the 108 women, 35 had laparoscopic hysterectomies (LH), 56 had laparoscopic-assisted vaginal hysterectomies (LAVH), and 9 had subtotal laparoscopic hysterectomies (SLH). Eight procedures were converted to laparotomy, two attempted LHs and six attempted LAVHs. In 22 cases, bipolar coagulation of vascular pedicles was done exclusively, in 58 the Endo GIA 30 stapler was used exclusively, and in 20 a combination of both modalities was used. Bilateral ureteral catheters were inserted 49 times. MEASUREMENTS AND MAIN RESULTS There were eight complications (8.0%): two blood transfusions, two cases of transient, asymptomatic pyrexia, two abdominal wall hematomas, one Richter hernia, and one urinary tract infection. The hernia repair was the only delayed laparotomy. The mean (+/-SEM) surgical time was 123 +/- 8 minutes (range 45-235 min), and the mean hospital stay was 1.48 days +/- 0.4 (range 1-5 days). Ninety-five of the 100 women who successfully underwent a laparoscopic procedure returned to work within 2 weeks (range 4-14 days, range 15-53 days for the remaining 5). CONCLUSION Hysterectomy performed or aided by the laparoscope, whether LH, LAVH, or SLH, is effective and safe as long as at least one member of the surgical team is an experienced and appropriately trained laparoscopic surgeon. Further studies are necessary to determine if the credentialing process for advanced laparoscopic surgery would be facilitated by a visiting professorship program.

Relationship of endometrial thickness with the menstrual timing of leuprolide acetate administration for preoperative preparation for hysteroscopic surgery.

STUDY OBJECTIVES To assess the relationship of menstrual timing of administration of gonadotropin-releasing hormone (GnRH) agonist on the effectiveness of endometrial thinning and unwanted uterine bleeding. DESIGN Prospective observational study. SETTING Gynecology department of a community hospital. PATIENTS One hundred consecutive women in a private practice, without submucous myomas, scheduled for transcervical endomyometrial resection or ablation. INTERVENTIONS A GnRH agonist was administered at an unspecified time of the menstrual cycle. Transcervical hysteroscopic endomyometrial resection or ablation was performed 1 month later. MEASUREMENTS AND MAIN RESULTS No significant statistical differences were seen in either the effectiveness of endometrial thinning or the occurrence or severity of unwanted uterine bleeding. CONCLUSIONS A GnRH agonist as pretreatment for endomyometrial resection or ablation can be administered at any time during the menstrual cycle with similar efficacy. Timing of surgery can be at the mutual convenience of patient and physician.