Philip G. Brooks

Hormonal inhibition of the endometrium for resectoscopic endometrial ablation

Attempts at inhibiting the thickness and vascularity of the endometrium in preparation for endometrial ablation by using different types of hormones have been reported. To evaluate the effects of two different progestins, danazol, and leuprolide acetate on the endometrium, compared with the features of early proliferative endometrium, histologic studies were done for at least five patients treated with each hormone who then underwent resectoscopic endometrial ablation for treatment of abnormal uterine bleeding. Significant and at times dramatic differences among the treatment groups were found, with progestin-prepared endometrium being the least successful and leuprolide-prepared endometrium the most successful. In addition, the prolonged suppression provided for a period of time after the procedure by depot leuprolide is likely to help inhibit endometrial regeneration and provide even better long-term success of the procedure.

Hysteroscopic findings after unsuccessful dilatation and curettage for abnormal uterine bleeding

In recent years numerous articles have reported on the inaccuracies of the dilatation and curettage procedure, citing a false-negative rate of up to 10% to 15%. Indeed, several articles have reported that, in this era of simplified endoscopy, the blind dilatation and curettage should no longer play a significant role in gynecologic diagnosis, but should be replaced by hysteroscopic evaluation and directed biopsy. We report the hysteroscopic findings in 29 patients for whom a blind curettage was performed within the previous year for the purpose of diagnosing the cause of abnormal uterine bleeding and attempting its cure. The remarkably high incidence of apparently missed pathologic factors (mainly submucous myomata) adds to the data confirming the lack of precision of dilatation and curettage, and supports the contention that diagnostic hysteroscopy is an essential tool in the management of abnormal uterine bleeding and the prevention of unnecessary hysterectomies.

Hysteroscopic training guidelines

Safety and outcome of surgical procedures are clearly linked to adequate training. The criteria suggested below are minimal requirements and not absolute requirements as determined by the Board of Trustees of the American Association of Gynecologic Laparoscopists. Surgeons are responsible for obtaining adequate training. Surgeons should not request privileges for procedures or the use of new technologies in which they have not received adequate training. This is especially true when new technologies are used. The burden for satisfying the adequacy of training and surgical competence of the surgeon before allowing direct patient care ultimately falls on the hospital/facility medical staff. Physicians seeking hysteroscopic training should: a. Be board eligible/certified in gynecology, b. Have unsupervised gynecologic privileges for patient care, OR c. Be in an accredited residency program in obstetrics and gynecology. The components of hysteroscopic training ideally will include: a. Didactic training. b. Hands-on laboratory training. c. Case observation (highly recommended). d. Preceptorship (highly recommended). The didactic portion should initially include diagnostic and operative hysteroscopy and be a minimum of 6 hours. It should be a CME-approved program and include: 1. Uterine anatomy 2. Options of distention media 3. Management of distention media 4. Energy sources 5. Instrumentation 6. Surgical indications and techniques for: a. diagnostic hysteroscopy b. adhesiolysis c. metroplasty d. polycystic ovary e. fibroid resection/vaporization f. endometrial ablation 7. Prevention and management ofhysteroscopic complications.

Venous air embolism during operative hysteroscopy

The world literature, including hospital and medicolegal case records, was reviewed to collate cases of venous air embolism resulting from the increasing number of operative hysteroscopies being performed. Seven women undergoing operative hysteroscopy for five different indications had clear-cut evidence of venous air embolism early in the course of the procedure. Five of these patients died. This complication is rare but devastating, resulting from traumatic opening into large uterine sinuses, especially with the patient in the Trendelenburg position, when the heart is below the level of the uterus. Several steps can be taken to try to prevent this problem.

Complications of fluid overload from resectoscopic surgery

Excess absorption of liquid distending media is one of the most frequent complications of operative hysteroscopy. Although most women recover uneventfully, we are seeing cases of permanent morbidity or death resulting from this complication.

One-year results of the Vesta system for endometrial ablation

STUDY OBJECTIVE To compare a distensible multielectrode balloon for endometrial ablation with electrosurgical ablation performed by a combined resection-coagulation technique. DESIGN Randomized, prospective trial (Canadian Task Force classification I). Setting. Eight centers. PATIENTS Women with menorrhagia validated with a standardized pictorial blood loss assessment chart (PBAC), without intracavitary organic uterine disease, who failed or poorly tolerated medical therapy. Intervention. Results in 122 patients treated by Vesta and 112 treated surgically, evaluable at 1 year, were compared, with success defined as monthly blood loss of less than 80 ml and avoidance of additional therapy. MEASUREMENTS AND MAIN RESULTS Pretreatment PBAC scores for patients treated by Vesta and resection or rollerball were 535+/-612 and 445 +/- 313, respectively; at 1 year they were 18+/-37 and 28+/-60, respectively. With PBAC below 75 as the definition of success, 86.9% of Vesta-treated patients were successful compared with 83.0% treated by rollerball or resection. Total amenorrhea, defined as no visible bleeding and no use of protective products, was 31.1% and 34. 8%, respectively. None of the outcome comparisons between treatments showed statistical difference. Complications in both groups were few and minor. Most (86.6%) Vesta procedures were carried out with paracervical block with or without intravenous sedation in an office or outpatient setting, compared with 79.7% epidural or general anesthesia for rollerball or resection. CONCLUSION The Vesta system of endometrial ablation is equally effective and safe as classic resectoscopic methods. Potential advantages include avoidance of fluid and electrolyte disturbance associated with intravasation of distending media, and ability to perform the procedure under local anesthesia in an office setting with less total operating time.

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%.

Removal of intra-abdominal intrauterine contraceptive devices through a peritoneoscope with the use of intraoperative fluoroscopy to aid localization.

The article describes the use of peritoneoscopy to locate displaced IUDs and gives 4 case histories, 2 of which include concomitant use of fluoroscopy. Peritoneoscopy obviates the use of colpotomy or laparotomy, both of which entail lengthy hospitalization and greater hazards. A radiolucent operating table is recommended to facilitate fluoroscopic examination. After localization of the IUD, the device is freed from any serosal attachment with a biopsy forceps inserted through a cannula; if necessary electrodesiccation can be used to aid incision. When free, the device is pulled through the lower midline trocar under direct visual supervision when the sleeve is large enough. The case histories stress that the longer the IUD is displaced in the abdominal cavity, the more difficult the removal; thus, each patient should be reexamined several months after insertion. Only radiopaque IUDs should be inserted to permit X rays in the event of complications.