E.C. Vilos

EXPERIENCE WITH 800 HYSTEROSCOPIC ENDOMETRIAL ABLATIONS

STUDY OBJECTIVE To determine the safety and efficacy of hysteroscopic endometrial ablation in women with menometrorrhagia. DESIGN Retrospective record review. SETTING A credentialing program in teaching and nonteaching hospitals. PATIENTS Eight hundred women who underwent endometrial ablation in 54 hospitals, with indications of abnormal uterine bleeding disrupting lifestyle, postmenopausal bleeding during hormone replacement therapy, poor surgical risk for hysterectomy, or desire to preserve the uterus. INTERVENTIONS Seventy percent of the patients were treated with danazol 100 to 600 mg/day for 6 to 12 weeks, 8% received gonadotropin-releasing hormone analogs, 7% received progestins, and 15% were given no preoperative treatment. Under appropriate anesthesia the cervix was dilated to 10 mm and the uterine cavity was distended with 1.5% glycine solution under gravity inflow of 80 to 100 cm water and outflow suction of 80 to 100 mm Hg pressure. Electrocoagulation with or without resection was completed using 100 and 125 W, respectively. MEASUREMENTS AND RESULTS At 12 months 60% of patients reported amenorrhea, 29% hypomenorrhea, 6% eumenorrhea, and 5% no change. Repeat ablation was performed in 4% of patients. An additional 2% had hysterectomy for malignancy (endometrium 2, sarcoma 1, atypical hyperplasia 1), pelvic pain (4), fibroids (4), persistent bleeding (3), and endometritis (2). The complication rate was 3.9%: false passage during cervical dilatation (6), uterine perforation (dilator 4, resectoscope 2, Laminaria 1), fluid absorption greater than 1500 ml (8), minor bleeding (5), endomyometritis (4), and intrauterine pregnancy (1). CONCLUSIONS Hysteroscopic endometrial ablation is a safe and effective treatment for women with menometrorrhagia.

ENDOMETRIAL ABLATION WITH A THERMAL BALLOON FOR THE TREATMENT OF MENORRHAGIA

STUDY OBJECTIVE To evaluate the safety and clinical efficacy of a uterine thermal balloon endometrial ablation system for the treatment of menorrhagia. DESIGN Prospective pilot study. SETTING University-affiliated teaching hospital. PATIENTS Thirty women with menorrhagia who met inclusion and exclusion criteria and signed informed consent. INTERVENTIONS Under general (9 women) or neuroleptic (21) anesthesia and paracervical block, a 16-cm long, 3-mm diameter catheter with a latex balloon at its tip, housing a heating element, was inserted blindly transcervically into the uterus and filled with sterile 5% dextrose in water solution (range 2-21 ml, mean 9.2 ml). The catheter was connected to a control unit that maintained the temperature at 87 degrees C, monitored the pressure, and terminated the treatment after 8 minutes. MEASUREMENTS AND MAIN RESULTS There were no intraoperative or postoperative complications. At 6 months 25 patients (83%) reported significant improvement in menorrhagia (amenorrhea 1, staining 4, hypomenorrhea 13, moderate improvement 7). By 12 months 23 women (77%) reported significant improvement (amenorrhea 1, staining 4, hypomenorrhea 13, moderate improvement 5). CONCLUSIONS Uterine balloon thermal therapy is a safe and effective option for women with menorrhagia. The procedure does not require additional training and expertise in operative hysteroscopy and the presently used energy sources. It requires no cervical dilatation (5 mm), is tolerated well under neuroleptic anesthesia, and potentially can be offered as an office procedure under local anesthesia.

Transvaginal Doppler-Guided Uterine Artery Occlusion for the Treatment of Symptomatic Fibroids: Summary Results From Two Pilot Studies

OBJECTIVE To evaluate the feasibility, safety, and short-term efficacy of bilateral uterine artery occlusion, using a transvaginal Doppler-guided vascular clamp as a minimally invasive therapy for symptomatic uterine leiomyomas. METHODS We conducted two prospective, non-randomized, phase I pilot studies (Canadian Task Force Classification II-2) at a university-affiliated teaching hospital. Between June 2004 and May 2005, 30 premenopausal women with symptomatic uterine leiomyomas underwent bilateral uterine artery occlusion using a transvaginal Doppler-guided vascular clamp. Bilateral uterine artery occlusion was performed for 5.8 +/- 1.4 hours in the first 17 patients (Group 1) and from 6 to 9 hours (mean 7.05 +/- 1.0 hours) in the latter 13 patients (Group 2). Outcome measures included dominant fibroid volume (cm(3)), uterine volume (cm(3)), and improvement of menorrhagia at one, three, and six months. RESULTS Bilateral occlusion of the uterine arteries was achieved in all 30 patients. In Group 1, the Ruta Menorrhagia Severity Scores decreased from baseline by 16%, 22% and 39% at one, three, and six months respectively. The dominant fibroid (DF) and uterine volumes decreased by 24% and 16% respectively at six months. In Group 2, the Ruta scores changed from baseline by +3%, -24%, and -42% at one, three, and six months respectively. The DF and uterine volumes decreased by 29% and 16%, respectively at six months. CONCLUSION Following bilateral uterine artery occlusion using a transvaginal Doppler clamp, the dominant fibroid volume decreased by an average of 24%, uterine volume decreased by 12%, and menorrhagia symptoms were reduced by up to 42%. Uterine artery occlusion may provide the gynaecologist with an alternative to uterine artery embolization (UAE). The system is simple, easy to apply, and short-term efficacy may be equivalent to UAE.