Endometrial cancer following endometrial resection

Endometrial ablation has emerged as a viable alternative to hysterectomy in the treatment of medically intractable dysfunctional uterine bleeding. However, this procedure cannot guarantee complete removal of the entire endometrium. Cases of endometrial cancer after endometrial ablation have been reported in the literature. We reviewed the cases of patients who underwent hysteroscopic endometrial ablation by endometrial resection for abnormal uterine bleeding from 1994 to 2005 at the Department of Obstetrics and Gynecology, Polyclinique, Clermont-Ferrand University. Of the 3769 patients having had hysteroresections, four developed endometrial cancer after complete endometrial ablation (1.06 out of 1000). All four of these patients showed histological evidence of endometrial polyps at endometrial resection, and all of them presented risk factors for endometrial carcinoma, such as obesity and/or arterial hypertension. Endometrial cancer after hysteroscopic endometrial ablation is a rare but possible occurrence, even a long time after the operation. Close monitoring of patients who have undergone endometrial ablation for endometrial polyps and who present risk factors, such as obesity or hypertension, even after apparent total ablation of the endometrium is strongly recommended, independently of the presence of abnormal bleeding that can represent a late symptom of advanced endometrial cancer.     

宫腔镜子宫内膜射频消融术与内膜电切术治疗围绝经期功血疗效比较研究

目的 探讨宫腔镜子宫内膜射频消融术与内膜电切术治疗围绝经期功能失调性子宫出血（功血）的不同临床疗效。方法 收集因围绝经期功血2009年1月至2013年8月于中国医科大学附属盛京医院行宫腔镜手术治疗患者的临床资料共132例,其中宫腔镜子宫内膜射频消融术（消融组）68例,宫腔镜子宫内膜电切术（电切组）64例。比较两组的手术时间、术中出血量、住院时间、治愈率及手术并发症,以评价两者的临床疗效。结果 消融组的手术时间、住院时间比电切组短,差异有统计学意义（P<0.05）;消融组的出血量较电切组少,差异有统计学意义（P<0.05）;消融组的治愈率为98.5%,虽优于电切组的93.8%,但两者差异无统计学意义（P>0.05）,两组均无手术并发症发生。结论 宫腔镜子宫内膜射频消融术治疗围绝经期功血疗效确切,值得在临床使用。     

Subtotal vaginal hysterectomy: A new role for an old procedure

Patients with persistent uterine bleeding that is unresponsive to conservative therapy may opt for endometrial ablation over total hysterectomy because of concerns over subsequent sexual dysfunction or other nonclinical issues. Twelve such women with healthy cervices who failed endometrial ablation, and eight candidates for ablation were offered subtotal vaginal hysterectomy as a definitive primary surgical intervention instead of endometrial ablation. Our experience suggests the safety and utility of subtotal vaginal hysterectomy in properly selected patients. Randomized, comparative studies of this technique as an alternative to hysteroscopic ablation or resection may be warranted.     

Efficacy and satisfaction rate comparing endometrial ablation by rollerball electrocoagulation to uterine balloon thermal ablation in a randomised controlled trial

OBJECTIVE: To compare two methods of endometrial ablation, hysteroscopic rollerball electrocoagulation (RBE) and non-hysteroscopic uterine balloon thermal ablation (Thermachoice trade mark ), regarding efficacy for reducing dysfunctional uterine bleeding and patients satisfaction rate. METHODS: A randomised controlled study was performed in a teaching hospital at the department of gynaecology. One hundred and thirty-seven premenopausal women with dysfunctional uterine bleeding proved by validated menstrual score list were included. Endometrial ablation by a hysteroscopic or non-hysteroscopic method was performed by one gynaecologist. RESULTS: Reduction of menstrual blood loss was significantly more successful at 24 months for thermal ablation with uterine balloon. Success rate measured by menstrual score < 185 for rollerball and thermal balloon ablation are equivalent at 12 and 24 months post-operatively. Satisfaction of the patients for both methods at 24 months post-operatively is not significantly different (respective 75% for rollerball and 80% for uterine balloon). CONCLUSIONS: Endometrial ablation by uterine balloon thermal ablation (Thermachoice trade mark ) is equally effective as hysteroscopic RBE of the endometrium.     

Endometrial stromal sarcoma diagnosed after hysteroscopic endometrial resection

Endometrial ablation and resection is now common therapy for dysfunctional uterine bleeding that is unresponsive to conservative management. Opponents argue that it may predispose patients to potentially hazardous malignancies of the uterus. In our patient, endometrial resection was performed to treat menorrhagia after a negative workup. Pathologic interpretation of the resected tissue showed a low-grade stromal sarcoma of the endometrium. The woman underwent definitive treatment, which included total abdominal hysterectomy, and has remained recurrence free over the past 3 years. Although rare, uterine malignancies have been documented after hysteroscopic management of menorrhagia. It is suggested that intraoperative endometrial resection or tissue sampling be done to prevent or diagnose endometrial hyperplasia and uterine malignancies.     

Endometrial Ablation: Complications and Outcome

Objective: to review the peri-operative complications and outcome of endometrial ablation.Design: review of 100 consecutive endometrial ablations using electrosurgery.Setting: teaching hospital.Patients: one hundred patients with disabling dysfunctional uterine bleeding, unresponsive to medical therapy, who chose endometrial ablation instead of hysterectomy.Results: peri-operative complications were minimal with the exception of one uterine perforation resulting in hysterectomy. The short-term success rate of surgery was 90 percent. Life table analysis suggests that by thirty months, success rates will have declined to 65 percent.Conclusions: endometrial ablation using electrosurgery has a low rate of peri-operative complications. Short-term success rates are high but life table analysis suggests long-term success rates may be much lower.     

Small bowel perforation after thermoregulated radiofrequency endometrial ablation: a case report

During the past decades, numerous hysteroscopic ablation techniques have been developed for the treatment of menorrhagia, all conferring relatively comparable success rates and low complication incidences. We here report an unusual, adverse, post-operative, complication of the Vesta thermoregulated radiofrequency endometrial ablation system in a 34-year-old nulliparous woman with dysfunctional uterine bleeding. Fourteen days after the procedure she presented with acute abdominal pain. At laparotomy, a small bowel perforation was identified, and the entire uterus was found to be necrotic, necessitating a total hysterectomy. This is the first report of a severe complication of this endometrial ablation system in the absence of uterine perforation. We propose that minimal myometrial thickness should be taken into consideration to improve the safety of thermoregulated radiofrequency endometrial ablation.     

Endometrial ablation: principles and technique

Uterine bleeding may be caused either by benign organic pathology as well as different dysfunctional conditions. Medical treatment with progestins, danazol or GnRH analogues is usually used as the first choice therapy. Where the symptoms persist, hysterectomy is generally proposed; it has been calculated that from 500,000 to 700,000 such operations are performed annually in the United States. The authors review the state of the art of the endometrial ablation as an alternative to hysterectomy and other medical therapy. Endometrial ablation either by means of the YAG-laser or with the resectoscope, would seem to play a role in well-selected cases of dysfunctional uterine bleeding. In the authors opinion a multicenter study on large numbers of patients is needed in order to confirm these preliminary results.     

Endometrial ablation by rollerball electrocoagulation compared to uterine balloon thermal ablation. Technical and safety aspects

Objective: To compare two methods of endometrial ablation, hysteroscopic rollerball electrocoagulation (RBE) and non-hysteroscopic uterine balloon thermal (UBT) ablation (Thermachoice™), regarding intra- and post-operative technical complications and safety aspects. Study design: A randomised controlled study in a teaching hospital, 139 pre-menopausal women with dysfunctional uterine bleeding proved by a validated menstrual score list were enclosed. Endometrial ablation by a hysteroscopic or non-hysteroscopic method was performed. Results: Rollerball electrocoagulation carries a significantly higher risk of intra-operative complications compared to uterine balloon thermal ablation and is a significantly more time consuming procedure. Post-operative complication rates in both groups were low, but post-operative analgesics were prescribed significantly more in the uterine balloon group. Conclusion: Endometrial ablation by uterine balloon thermal ablation (Thermachoice™) is a safe and simple non-hysteroscopic procedure.     

Hysteroscopic endomyometrial resection of three uterine sarcomas.

STUDY OBJECTIVE: To describe our experience with three uterine sarcomas associated with hysteroscopic endometrial ablation. DESIGN: Cohort study (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospitals. PATIENTS: Three of 2402 women undergoing hysteroscopic endometrial ablation who had uterine sarcomas. INTERVENTION: Hysteroscopic endomyometrial resection. MEASUREMENTS AND MAIN RESULTS: One low-grade endometrial stromal sarcoma and two carcinosarcomas were resected. After hysterectomy in two patients, no residual cancer was identified in one of them. The third patient was an 82-year-old woman with moderate menorrhagia who refused hysterectomy. After endomyometrial resection she remained amenorrheic for the last 14 months of her life. CONCLUSION: From our experience the incidence of uterine sarcomas is approximately 1/800 women undergoing hysteroscopic ablation for abnormal uterine bleeding. Complete endomyometrial resection is feasible and may be offered as diagnostic and palliative therapy in women at high risk for hysterectomy.     

Altered uterine artery blood flow impedance after danazol therapy: possible mode of action in dysfunctional uterine bleeding.

OBJECTIVE: To test the hypothesis that danazol increases the impedance to uterine circulation and hence reduces the effective uterine blood flow after a predetermined period of therapy. DESIGN: Prospective, longitudinal study. SETTING: Reproductive medicine unit of a university teaching hospital. PATIENT(S): Eight premenopausal women with dysfunctional uterine bleeding. INTERVENTION(S): Six weeks of danazol therapy. MAIN OUTCOME MEASURE(S): The uterine artery blood flow impedance as indicated by the pulsatility and resistance indices; the hormonal profile (E2, FSH, and LH levels); the uterine dimensions (length, width, anteroposterior diameter, and area); and the endometrial thickness. RESULT(S): The indices of uterine artery impedance were significantly increased after danazol therapy, indicating a possible reduction in the effective uterine artery blood flow. There was no statistically significant change in the hormonal profile, uterine dimensions, or endometrial thickness. CONCLUSION(S): Danazol therapy for 6 weeks results in a significant increase in the uterine artery impedance and hence a possible reduction in the effective uterine artery blood flow. This may explain in part its efficacy in the management of dysfunctional uterine bleeding and in the preoperative preparation of women undergoing endoscopic endometrial ablation. The exact mechanism for its action in this regard remains to be determined but appears to be independent of E2 levels. This preliminary finding may help in monitoring the treatment of dysfunctional uterine bleeding, preoperative and postoperative investigation of women undergoing endoscopic endometrial ablation, and the development of alternative treatment strategies for dysfunctional uterine bleeding in the future.     

Endometrial laser intrauterine thermotherapy: the first series of 100 patients observed for 1 year

OBJECTIVE: To describe a new instrument (GyneLase) that offers a new approach (endometrial laser intrauterine thermal therapy [ELITT]) to treatment of menorrhagia and to evaluate the efficacy of ELITT in the management of dysfunctional uterine bleeding. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): 100 premenopausal women with dysfunctional uterine bleeding were observed for 1 year. INTERVENTION(S): Intrauterine laser thermotherapy with a diode laser. MAIN OUTCOME MEASUREMENT(S): Amenorrhea rate after 1 year. RESULT(S): The amenorrhea rate after 1 year of follow-up was 71%, and the rate of amenorrhea/severe hypomenorrhea rate was >90%; these rates are much higher than those in the literature after such procedures as electrosurgery or intrauterine thermal balloon therapy. The ELITT procedure is an inherently safe and simple alternative, providing controlled and effective treatment of the entire endometrium. In contrast to traditional endometrial ablation using a neodymium yttrium-aluminum-garnet laser, the ELITT procedure does not require intensive training or hysteroscopic control; it is also far less risky, because the power used per unit area is 1,000 times lower. CONCLUSION(S): The ELITT procedure is a new nonhysteroscopic technique for endometrial ablation. The technique is very safe and offers the highest amenorrhea rate to date in the literature.     

Has endometrial ablation replaced hysterectomy for the treatment of dysfunctional uterine bleeding? National figures

Objectives To describe trends in the use of endometrial ablation and hysterectomy for the treatment of dysfunctional uterine bleeding.
Design Analysis of hospital admissions data.
Setting National Health Service Hospitals in England.
Population Women who underwent a hysterectomy or endometrial ablation for dysfunctional uterine bleeding between 1989 and 1996.
Main outcome measures Annual operation rates and standardised operation ratios for England and for the National Health Service Regions within it, and proportion of operations for dysfunctional uterine bleeding that were endometrial ablations or hysterectomies.
Results There was an initial rise in operation rates for endometrial ablation until 1992/3, since when the rates have fallen. Hysterectomy rates have remained relatively steady since the introduction of endometrial ablation. The total operation rates for dysfunctional uterine bleeding initially increased but have tended to fall since 1992/3. The ratio of hysterectomy to endometrial ablation for dysfunctional uterine bleeding troughed at 3:1 in 1992/3, but by 1995/6 had increased to 4:1.
Conclusions Rather than replacing hysterectomy in the treatment of dysfunctional uterine bleeding, endometrial ablation appears to have added an alternative operative technique. This led to an increase in the total number of operations for this condition, perhaps by lowering the threshold for intervention.     

Hysterectomy as treatment for dysfunctional uterine bleeding.

The surgical treatment of patients with dysfunctional uterine bleeding (DUB) is discussed in this chapter, including indications, techniques and complications. Hysterectomy is the definitive treatment for DUB; in most studies it has a higher rate of patient satisfaction than does hysteroscopic endometrial ablation. The vaginal or laparoscopic approach should be selected in this group of patients with small uteri, while laparotomy is seldom indicated. In general, the indications for vaginal hysterectomy and endometrial ablation differ from those of laparoscopic hysterectomy. Ablation and vaginal hysterectomy are done for hypermenorrhoea, while laparoscopic hysterectomy is best when pathology is present, usually adhesions, endometriosis or fibroids.     

Patient satisfaction with thermal balloon endometrial ablation. A retrospective review

OBJECTIVE: To determine overall patient satisfaction with the balloon endometrial ablation procedure in women with menorrhagia. STUDY DESIGN: Thirty-one women in a university hospital underwent thermal balloon endometrial ablation in the year 2000. Of these, 3 were lost to follow-up. Twenty-eight women were called and asked to participate in a survey that quantified overall satisfaction with the procedure as well as change in menstrual flow and menstrual pain. Women were asked if any further medical or surgical therapy was required to control the bleeding. All patients participated in the study and stated that they underwent the procedure secondary to "heavy bleeding." All operative reports were reviewed and contained menorrhagia, menometorrhagia or dysfunctional uterine bleeding in the preoperative diagnosis. RESULTS: A total of 57% of women reported overall satisfaction with the endometrial ablation procedure, 14% were very dissatisfied, and 4% were neutral. Fifty-seven percent of women reported no bleeding or very decreased bleeding following the procedure, while 11% had slightly decreased bleeding. Thirty-two percent experienced no change, 43% reported decreased menstrual pain, and 57% had no change. Thirteen of 28 women underwent subsequent hysterectomy. CONCLUSION: Less than 60% of women reported satisfaction with balloon endometrial ablation, and 40% underwent hysterectomy within 1 year of it.     

射频热凝固治疗无排卵型功能失调性子宫出血预后差异性的Meta分析

目的:评价射频热凝固(RF)治疗无排卵型功能失调性子宫出血(ADUB)的疗效。方法:检索2002年9月1日至2012年9月1日Cochrane图书馆、MEDLINE、PubMed、Web of Science、万方数据库(CECDB)、维普中文科技期刊全文数据库(CQVIP)、中国学术期刊全文数据库(CNKI),提取纳入文献的资料,并严格评价文献质量。应用Review Manager 5.0软件对符合质量标准的随机对照试验(RCT)进行Meta分析。结果:最终纳入6篇RCT研究,共计313例患者,其中治疗组(使用RF)156例,对照组(使用宫腔镜内膜电切除术、微波内膜去除术)157例。两组患者均进行常规口服孕激素和对症支持治疗。Meta分析结果显示:与对照组比较,治疗组治疗3个月后PBAC(月经量评分)显著下降(WMD为-22.70,95%CI为-24.65～-20.75)、痛经症状显著缓解(RR=0.62,95%CI为0.40～0.95)、Hb含量显著上升(WMD为23.83,95%CI为21.47～26.19),差异均有统计学意义。结论:RF较宫腔镜内膜电切除术和微波内膜去除术,能显著提高ADUB的疗效。     

The alternatives to hysterectomy.

Hysterectomy is one of the commonest major operations, with 72,362 procedures performed in England in 1993. However, for women with dysfunctional uterine bleeding other less invasive surgical options have been developed. In particular, hysteroscopic endometrial ablation has been shown to be an effective therapy. Prospective randomized trials have shown that hysteroscopic surgery is associated with a shorter operating time, fewer complications, less analgesic requirement, a faster resumption of normal activities and work and savings in treatment costs. Psychological and social functioning also improves with no significant differences compared to hysterectomy. There is, however, a tendency for women randomized to hysterectomy to report higher rates of satisfaction. Several non-hysteroscopic ablative techniques are currently being developed and tested. While attractive, as they do not require significant hysteroscopic skills and will probably prove to have fewer operative risks than hysteroscopic procedures, the results of these procedures are still in the evaluation phase.     

A randomized prospective comparative study of general versus epidural anesthesia for transcervical hysteroscopic endometrial resection

OBJECTIVE: This study was undertaken to compare general versus epidural anesthesia during hysteroscopic endometrial resection for dysfunctional uterine bleeding. STUDY DESIGN: In a prospective comparative study, 24 women with abnormal uterine bleeding that was unresponsive to conservative medical management were randomly assigned to undergo hysteroscopic endometrial resection with either general or epidural anesthesia. RESULTS: The durations of the endometrial resection procedure were similar for women who had general and epidural anesthesia (28.3 +/- 4.2 minutes vs 27.5 +/- 5.4 minutes, respectively). However, there was a statistically significantly lower absorption of distention fluid in women who underwent the procedure with general rather than epidural anesthesia (380.8 +/- 158.2 mL vs 648.3 +/- 157.1 mL, respectively; P < .0005). CONCLUSION: A significantly lower amount of glycine distention fluid was absorbed during endometrial resection in women who underwent the procedure with general rather than epidural anesthesia.     

Frequency of symptomatic cornual hematometra and postablation tubal sterilization syndrome after total rollerball endometrial ablation: a 10-year follow-up

OBJECTIVE: This study was undertaken to determine the frequency of symptomatic cornual hematometra and postablation tubal sterilization syndrome after total rollerball endometrial ablation and to describe methods for diagnosis, treatment, and prevention. STUDY DESIGN: Retrospective cases of 50 consecutive patients who received total rollerball endometrial ablation for dysfunctional uterine bleeding were followed up for 10 years. RESULTS: Symptomatic cornual hematometra or postablation tubal sterilization syndrome was diagnosed by ultrasound scanning and/or magnetic resonance imaging in 5 of 50 patients (10%) who had a total endometrial ablation. Two patients had cornual hematometra, and 3 patients had postablation tubal sterilization syndrome 4 months to 90 months after rollerball ablation. Subsequent gonadotropin-releasing hormone agonist treatment or hysteroscopic decompression of the hematometra was only partially successful, and recurrence of symptoms necessitated hysterectomy with salpingectomy. CONCLUSION: Uterine contracture, which obstructs bleeding from persistent cornual endometrium and leads to symptomatic cornual hematometra or postablation tubal sterilization syndrome, is not uncommon after total rollerball endometrial ablation, with an incidence of 10% in our series. Satisfactory treatment requires hysterectomy with salpingectomy, but modifications such as partial endometrial ablation can prevent these complications.     

Polypectomy in premenopausal women with abnormal uterine bleeding: effectiveness of hysteroscopic removal

STUDY OBJECTIVE: To estimate the effectiveness of hysteroscopic polypectomy in premenopausal women with abnormal uterine bleeding and to identify prognostic factors for persistence or recurrence of symptoms after polypectomy. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University teaching hospital. PATIENTS: Premenopausal women with abnormal uterine bleeding. INTERVENTION: Hysteroscopic polypectomy, regardless of whether combined with endometrial ablation or insertion of a levonorgestrel-releasing intrauterine device. MEASUREMENTS AND MAIN RESULTS: Seventy-eight consecutive patients met the inclusion criteria and were followed over time. Data were retrieved from medical records or from additional questionnaires sent to the patients. Failure of treatment was defined as persistence or recurrence of abnormal uterine bleeding after polypectomy, requiring further treatment. The mean age was 44.2 years (SD 5.2, 95% CI 33.9-54.4 years). Intervention-free survival after polypectomy, as calculated by Kaplan-Meier survival analysis, was 41.1% (SE 8.3%, 95% CI 24.8%-57.4%) after 4 years for patients who underwent only hysteroscopic polypectomy and 54.7% (SE 13.6%, 95% CI 28.0%-81.4%) for patients who underwent a polypectomy combined with endometrial ablation or insertion of a levonorgestrel-releasing intrauterine device (p = .08). Cox regression analyses revealed no statistically significant predictors for persistence or recurrence of symptoms after polypectomy. CONCLUSION: Nearly 60% of patients required further treatment for persistence or recurrence of abnormal uterine bleeding 4 years after hysteroscopic polypectomy. Although not significant, outcome of treatment tended to improve by combining polypectomy with either an endometrial ablation or insertion of a levonorgestrel-releasing intrauterine device.