O Brandes-Klein

Immediate versus delayed treatment of perimenopausal bleeding due to benign causes by balloon thermal ablation.

STUDY OBJECTIVE To compare the effectiveness and safety of thermal balloon ablation without pretreatment with endometrium-thinning agents compared with delayed ablation with pretreatment for women with perimenopausal menorrhagia. DESIGN Prospective, randomized, controlled trial (Canadian Task Force classification I). SETTING Hospital-based ambulatory medical center. PATIENTS Thirty women age 46 to 51 years with severe enough perimenopausal menorrhagia to make them candidates for either hysterectomy or endometrial ablation. Two patients with submucosal myomas and six who had undergone cesarean section were included. INTERVENTIONS Thirteen patients were randomly assigned to be treated within 30 days and received a single intramuscular administration of gonadotropin releasing hormone (GnRH) analog; 17 women were allocated to be treated within 3 days of enrollment without uterine preparation. A thermal balloon was inserted transcervically under general anesthesia, and after inflation in the endometrial cavity with 5% dextrose in water, was heated to 87 degrees C for 8 minutes. MEASUREMENTS AND MAIN RESULTS Immediate and long-term major and minor complications and success rates were analyzed. Bleeding patterns and mean duration of menstrual flow were compared between groups at 6-month follow-up. No major intraoperative or postoperative complications occurred in either group, including the women who had recently undergone hysteroscopic myomectomy or had a history of cesarean section. Minor side effects were similar in both groups, and did not exceed 5%. Overall, at 6-month follow-up, 7 women were amenorrheic, 20 hypomenorrheic, and 3 eumenorrheic. No significant differences were noted between women treated with immediate or delayed ablation in either the distribution of bleeding patterns or days of flow per cycle (mean +/- SEM 1.8 +/- 0.42 vs 2.1 +/- 0.75 days, respectively). CONCLUSION This pilot study suggests that prompt treatment of perimenopausal menorrhagia with thermal balloon endometrial ablation is as effective and safe as deferred therapy combined with GnRH analog as an endometrium-thinning agent. In light of our results, the theory that previous cesarean section and presence of small submucosal myomas constitute relative contraindications for the procedure merits further consideration. (J Am Assoc Gynecol Laparosc 6(2):145-150, 1999)

Cystoscopy after total or subtotal laparoscopic hysterectomy: the value of a routine procedure

Ureteral injury during hysterectomy is one of the most troubling complications gynecologists need to be aware of. In various studies, such injury occurred in laparotomy, laparoscopy, and vaginal hysterectomy. The objective of our study was to assess the necessity, efficiency, and cost-effectiveness of cystoscopy at the end of total or subtotal laparoscopic hysterectomy (TLH/STLH). This is a retrospective analysis of 7 years’ experience in a university-affiliated hospital. All hysterectomies were performed on an overnight basis by experienced surgeons. Out of 338 patients, 106 patients underwent TLH, and 232 underwent STLH. Four cases (1.18%) of ureter injury were noted (one after TLH and three after STLH). Diagnosis was clinically made by postoperative vaginal sonography and was confirmed by intravenous pyelography. A cystoscopy was performed after intravenous indigo carmine injection. The study period consisted of two phases. In the first phase, we used bipolar cautery to occlude the uterine artery; consequently, a nearby thermal injury could be misdiagnosed. In the second phase we clipped the uterine artery with a new hemoclip called Hem-o-lok (Weck Closure Systems, USA), which forced an exact uterine artery closure. As a result, in the second phase no cases of ureteral injury were noted. In view of the fact that the equipment for cystoscopy is used during surgery for TLH/STLH and is sterile and available, the only additional cost of the cystoscopy is an ampule of indigo carmine. Therefore, we conclude that cystoscopy at the end of surgery for TLH/STLH is an important evaluation and provides the following significant advantages: In patients presenting with postoperative flank pain, cystoscopy may prevent the need for further evaluation and expensive testing, and cystoscopy increases the surgeon’s and the patient’s confidence in the integrity of the urinary tract during the recovery period.

Endometrial Ablation for the Postmenopausal Woman

The postmenopausal woman with abnormal uterine bleeding is considered at risk for developing endometrial neoplasia or one of its precursors. She requires prompt evaluation of the endometrium followed by adequate treatment. In the subgroup of postmenopausal women taking hormone replacement therapy (HRT), the risk of abnormal bleeding is by far higher, is the main reason for discontinuing HRT, and deserves additional attention.