Long-term outcome of hysteroscopic endometrial resection with or without myomectomy in patients with menorrhagia

Objectives  To evaluate the long-term outcomes and hysterectomy rates after hysteroscopic endometrial resection with or without myomectomy for menorrhagia. Study design  Fifty-three women who had submucous myomas with intramural extension of less than 50% and smaller than 5 cm in diameter underwent endometrial resection and concomitant hysteroscopic myomectomy. Each of them was matched with a patient who had no submucous myomas and who had been treated by endometrial resection only. These two groups were compared for operative outcomes, additional procedures, outcome of menstrual bleeding and for subsequent hysterectomy, which was the endpoint of this study. Results  During the mean follow-up period of 6.5 years, 18 (34.6%) women with endometrial resection and myomectomy and 21 (39.6%) without myomectomy underwent at least one gynecological procedure. Hysterectomy was performed in 26.9% [95% confidence interval (CI) 16.8–40.3] of the patients with myomectomy and in 17.0% (95% CI 9.2–29.2) of the patients without myomectomy (P = 0.22). The main indications for hysterectomy were pain and spotting bleeding in seven out of 14 cases with myomectomy and in four out of nine with endometrial resection only. Leiomyomas were found in 12 out of the 14 women who had hysterectomy after hysteroscopic myomectomy and in four out of nine with hysterectomy after endometrial resection only (P = 0.06). Most (75.6%) of the 82 women who had not required hysterectomy had reached menopause. All the patients without hysterectomy in both groups reported amenorrhea or slight bleeding, and this response maintained for years after the treatment. Conclusion  Endometrial resection may be combined with hysteroscopic myomectomy without a significant increase or decrease in hysterectomy rates during a long-term follow-up.     

Endometrial resection following levonorgestrel intrauterine system treatment for menorrhagia

The objective of this study was to evaluate long-term outcomes and hysterectomy rates after hysteroscopic endometrial resection among women following use of a levonorgestrel-releasing intrauterine system (LNG-IUS) for menorrhagia and among women never using this. Forty-five women who had used LNG-IUS for treatment of menorrhagia underwent endometrial resection. Each of them was matched with a patient who had never used LNG-IUS and who had been treated by endometrial resection for menorrhagia (control group). These two groups were compared for operative outcomes, additional procedures, outcome of menstrual bleeding, and for subsequent hysterectomy, which was the endpoint of this study. During the mean follow-up period of 5.8 years, 19 (44%) women undergoing endometrial resection following LNG-IUS and 14 (31%) with endometrial resection and without use of LNG-IUS underwent at least one gynecological procedure. Hysterectomy was performed in 14 (33%) women who had used LNG-IUS and in seven (16%) in the control group (p = 0.05). The main indications for hysterectomy were pain and enlarged uterus; leiomyomas and/or adenomyosis were found in specimens of the uterus extirpated, except for two cases with hematometra in both groups. Patients not hysterectomized reported amenorrhea or slight bleeding, and this response persisted for years after the treatment. In conclusion, two of three women avoided hysterectomy when endometrial resection followed LNG-IUS although hysterectomy rate was higher than those who had never used the device. Hysteroscopic surgery may be considered as an alternative to hysterectomy after discontinuation of LNG-IUS for menorrhagia.     

Transcervical endometrial resection in women with menorrhagia: long-term follow-up

OBJECTIVE: Hysteroscopic endometrial resection is an innovative and conservative surgical technique considered, very often, as an alternative to hysterectomy. The aim of the study was to evaluate long-term efficacy of endometrial resection performed in women with menorrhagia. STUDY DESIGN: Retrospective study of 111 premenopausal women with menorrhagia, unresponsive to medical treatment, who underwent endometrial resection by resectohysteroscope (electrocautery technique supplied with a fundus rollerball electrode, with corneal areas, and with a 90 degrees loop for intrauterine walls and used with glycine 1% as distending fluid) between 1994 and 1999. RESULTS: Long-term follow-up questionnaires were completed in 106 cases, while 5 cases dropped-out (4.5%). The mean-age at menopause in our subjects was 52.8 years (17.6+/-18.4 months after operation). After 53.2+/-16.4 months, 82 patients (77.4%) showed a normal menstrual pattern or amenorrhea, while failure was recorded in 24 patients (22.6%) and 12/24 patients underwent hysterectomy. Percentage of success in the older population (>49 years) (94%) was significantly higher than in the younger population (70%). The histologic finding of only fibrosis (41.7%) correlated with failure of the technique. CONCLUSION: Our data suggest that endometrial resection by resectohysteroscope is an innovative and conservative but not exclusive surgical technique in selected younger women, while in older women endometrial resection nearly always resolves long-term menorrhagia.     

Long-term outcome of hysteroscopic endometrial ablation without endometrial preparation

OBJECTIVE: To describe the three-step hysteroscopic endometrial ablation (EA) technique without endometrial preparation, and its long-term outcomes. STUDY DESIGN: Four hundred and thirty-eight premenopausal women with menorrhagia or menometrorrhagia underwent three-step hysteroscopic EA, which consists of rollerball ablation of the fundus and cornual regions, a cutting loop endomyometrial resection of the rest of the cavity, and rollerball redessication of the whole pre-ablated uterine cavity. The main outcome measures were menstrual status, level of satisfaction with the procedure, and the need for repeat ablation or hysterectomy. Questionnaires were completed for 385 women (87.9%) with a mean follow-up of 48.2 months. RESULTS: One hundred and eighty-four responders (47.8%) reported amenorrhea; 177 (46%) had light to normal flow. One patient (0.3%) underwent repeat ablation and 20 (5.2%) underwent hysterectomy: 15 (3.9%) because of endometrial ablation failure and 5 (1.3%) because of indications unrelated to the ablation (three cases of atypical endometrial hyperplasia and two cases of fibroids). Two hundred and ninety-two patients (75.8%) were very satisfied, and 78 (20.3%) satisfied with the results. No major complications occurred and three women (0.8%) became pregnant during the follow-up period. CONCLUSIONS: EA is safe and effective means of treating of menorrhagia and menometrorrhagia in premenopausal women, and helps avoid hysterectomy in 95% of patients suffering from heavy bleeding, with or without uterine fibroids. Women should be informed that the procedure is not contraceptive and that pregnancy is possible after treatment.     

Management of menorrhagia with the levonorgestrel intrauterine system versus endometrial resection

Menorrhagia is the presenting symptom among the majority of women who undergo hysterectomy. The levonorgestrel intrauterine system (LNG-IUS) is highly effective in reducing menstrual bleeding. The aim of this randomized study was to compare the effect of endometrial resection (ER) as a surgical modality and the LNG-IUS as a hormonal modality for treating menorrhagia. This is a therapeutic, phase III randomized study that included 60 premenopausal women with excessive uterine bleeding. The patients were randomly allocated to two treatment groups – LNG-IUS or endometrial resection (ER). Uterine bleeding was quantified by the pictorial blood loss assessment score (PBAC). The degree of disturbance caused by menstrual bleeding on general well-being, work performance, physical activity and sexual activity was assessed using a visual analogue scale at screening. Initial evaluation was followed by reassessment at 6 months, and at 12 months or at discontinuation. Both groups were matched for age, duration of flow and uterine characteristics. In the LNG-IUS group, four patients discontinued treatment and, ultimately, treatment success was 77%. In the ER Group, all operations were uneventful. A significant reduction in the amount of blood loss monthly was achieved in 83% of the cases, and there was a significant improvement in the quality of life of the patients in both study groups. The difference between the two groups was not statistically significant (p=0.747). The placement of LNG-IUS has a dramatic effect in lowering bleeding intensity in menorrhagic patients, with the advantage of reversibility, and mild adverse events. It may be the first-line treatment in younger women with menorrhagia.     

Patient outcomes following an endometrial thermal balloon ablation (thermochoice) procedure for menorrhagia in a day surgery unit

This study was carried out to assess the efficacy, complication rate and acceptability of endometrial thermal balloon ablation in a District General Hospital in the South West of England.     

Hysteroscopic myomectomy for menorrhagia using Versascope™ bipolar system: Efficacy and prognostic factors at a minimum of one year follow up

Objective

To evaluate the effectiveness of hysteroscopic submucous myomectomy for women with heavy menstrual bleeding (HMB) over a minimum 1-year period and assess prognostic factors associated with treatment success.

Study design

Prospective observational study set in a university teaching hospital in UK involving 92 women symptomatic of HMB with submucous myomas consecutively recruited between June 2003 and November 2006. Hysteroscopic myomectomy was performed under outpatient local anaesthetic (n = 35, 38%) or daycase general anaesthesia (n = 57, 62%) using Gynecare Versascope™ bipolar system. The main outcome measures were: the need for secondary surgical or medical re-intervention, menstrual improvement and patient satisfaction. Other outcome measures include: successful completion of primary resection, type of secondary treatment.

Result

Mean follow up was 2.6 years (95% CI 2.3–2.9). Complete fibroid excision was achieved in 66%. Secondary surgical re-intervention was required in 27 (29%) of which 11 (12%) were repeat hysteroscopic myomectomy and 10 (11%) were hysterectomy procedures. Multiple uterine fibroids and adenomyosis were identified in 80% of hysterectomies. At follow up, improved menstrual symptoms and patient satisfaction were reported by 91% and 86%, respectively. Irregular cycle HMB and incomplete fibroid excision were associated with secondary retreatment. Size of the submucous fibroid resected, presence of intramural and subserosal fibroids, or LA vs. GA setting were unrelated to treatment success.

Conclusion

HMB with submucous myomas may be successfully treated by completely removing the intracavity myoma component, irrespective of co-existent intramural or subserosal fibroids or size of fibroid resected. This effect remains sustained over at least a 1–2 year period.     

Prognostic factors for the success of endometrial ablation in the treatment of menorrhagia with special reference to previous cesarean section

Objective

To assess whether, among other prognostic factors, a history of Cesarean section is associated with endometrial ablation failure in the treatment of menorrhagia.Study design We compared women who had failed ablation to women who had successful ablation for menorrhagia in a case–control study. Failed ablation was defined as the need for hysterectomy due to persistent heavy menstrual bleeding after ablation. Successful ablation was defined as an ablation for menorrhagia not needing hysterectomy and the woman being satisfied with the result. Both cases and controls were identified from the surgery registration in the Máxima Medical Center between January 1999 and January 2009. Cases were women that had an endometrial ablation and a hysterectomy, whereas controls only had an endometrial ablation. From the medical files we collected for each patient clinical history, including the presence of a previous Cesarean section, baseline characteristics at the moment of initial ablation, data of the ablation technique and follow-up status. We used univariable and multivariable logistic regression to estimate the risk of failure of endometrial ablation.

Results

We compared 76 cases to 76 controls. Among the cases, 12 women had had a previous Cesarean section versus 15 in the control group (15.8% versus 19.7%; odds ratio (OR) 0.76; 95% CI 0.3–1.8). Factors predictive for failure of ablation were dysmenorrhea (OR 3.0; 95% CI 1.5–6.1), having a submucous myoma (OR 3.2; 95% CI 1.5–6.8) and uterine depth (per cm OR 1.3; 95% CI 1.0–1.6). Presence of intermenstrual bleeding, sterilization and age were not associated with failure of ablation.

Conclusion

A previous Cesarean delivery is not associated with an increased risk of failure of endometrial ablation, but dysmenorrhea, a submucous myoma and longer uterine depth are. This should be incorporated in the counseling of women considering endometrial ablation.     

Risk factors for vaginal prolapse after hysterectomy

Objective

To identify risk factors for pelvic organ prolapse (POP) and their influence on the occurrence of vaginal prolapse after hysterectomy.

Methods

Medical records from 2 groups of women who had undergone hysterectomy were reviewed retrospectively. The study group was 82 women who had undergone surgery for vaginal prolapse after hysterectomy; the control group was 124 women who had undergone hysterectomy with no diagnosis of vaginal prolapse by the time of the study. All hysterectomy procedures had been performed for benign gynecological disease, including POP. Both groups of women completed a self-administered questionnaire to obtain additional information on the occurrence of POP.

Results

The incidence of vaginal prolapse after hysterectomy was significantly higher in women with a higher number of vaginal deliveries, more difficult deliveries, fewer cesareans, complications after hysterectomy, heavy physical work, neurological disease, hysterectomy for pelvic organ prolapse, and/or a family history of pelvic organ prolapse. Premenopausal women had vaginal prolapse corrected an average of 16 years after hysterectomy, and postmenopausal women 7 years post hysterectomy.

Conclusion

Before deciding on hysterectomy as the approach to treat a woman with pelvic floor dysfunction, the surgeon should evaluate these risk factors and discuss them with the patient.     

Variable pressure cornual resection. Does radical hysteroscopic surgery give better results?

The radicality of the resective technique at transcervical endometrial resection (TCRE) may affect both the safety and efficacy. We evaluated both a more and a less extreme technique and compared results with our standard TCRE. A nonrandomised, prospective cohort study of three standardised endometrial resection/ablation techniques, each with differing tissue destruction profiles, was performed on 270 patients. Percentage reduction in bleeding, satisfaction, complications, and failures were recorded. Group 1 had standard loop resection circumferentially from the fundus to the internal os with current blend 1, power 120/60 W. The method for group 2 was the same as for group 1, with additional radical cornual resection followed by rollerball ablation to the entire cavity and cervical canal using the same power settings. To establish the safety of the cornual resection component, 25 cases were performed under laparoscopic control. In the first 15 cases, the extra cornual material excised was weighed separately and its contribution to the total weight calculated. Group 3 had slow low-power rollerball ablation to the cavity, cornua, and cervical canal with unmodulated power at 30 W. There were 68, 131, and 71 patients in the respective groups, followed up for a maximum of 36 months, with amenorrhoea rates of 31%, 36%, and 31%. Failure (a need for a further procedure) occurred in 18%, 12%, and 20%, respectively, and the preoperative to postoperative percentage reduction in bleeding between groups 2 and 3 was 78% (standard deviation 26) and 79% (standard deviation 33). There were no statistical differences in clinical outcome measures, complications, or satisfaction rates. The extra cornual endometrium comprised a mean additional 9%. This study did not support the premise that more radical techniques confer advantage in clinical outcome, although a trend towards a lower failure rate with the radical resection method may achieve significance with greater numbers. Principally, the greater failure rate in the rollerball group was due to cyclical pain despite improvement in bleeding score. Where satisfaction and safety is consistently high, the most straightforward procedure of rollerball ablation may be preferable, but the possible higher failure rate with this technique will require further qualification.     

Comparison of serum anti-Mullerian hormone levels following hysterectomy and myomectomy for benign gynaecological conditions

Objective

To compare serum anti-Mullerian hormone (AMH) levels following hysterectomy and myomectomy.

Study design

Prospective longitudinal observational study. Serum AMH, follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels were measured pre-operatively (T1) and 2 days (T2) and 3 months (T3) following hysterectomy and myomectomy in 70 women aged 36–45 years. Hysterectomy (laparoscopy-assisted vaginal hysterectomy = 10; total abdominal hysterectomy = 25) with conservation of both ovaries for benign diseases of the uterus was performed in 35 women, and myomectomy (laparoscopy myomectomy = 15; open myomectomy = 20) was performed in another 35 women. The follow-up period was 3 months following surgery. The results were analysed using the t-test or one-way analysis of variance by repeated-measures ANOVA.

Results

Serum AMH in the hysterectomy group was 1.08 ± 0.77 ng/ml at T1, 0.78 ± 0.58 ng/ml at T2 and 0.81 ± 0.58 ng/ml at T3; the level was significantly lower at T2 and T3 compared with T1. In the myomectomy group, the corresponding values were 1.54 ± 0.95 ng/ml, 1.18 ± 0.77 ng/ml and 1.50 ± 0.58 ng/ml; serum AMH was significantly lower at T2 compared with T1, but the difference between T3 and T1 was not significant. There were no significant differences in serum FSH and LH in either group between these three time points.

Conclusion

Serum AMH was significantly lower 2 days and 3 months following hysterectomy compared with the pre-operative level. Following myomectomy, serum AMH was significantly lower than the pre-operative level 2 days following the procedure, but was similar to the pre-operative level 3 months after surgery. Therefore, hysterectomy may have a more lasting adverse effect on ovarian reserve than myomectomy. A long-term study of AMH levels is needed.     

NovaSure impedance controlled system for endometrial ablation: three-year follow-up on 107 patients

OBJECTIVE: This study was undertaken to assess the safety, efficacy, and data durability of the NovaSure ablation at 3 years after the procedure in women with menorrhagia secondary to dysfunctional uterine bleeding (DUB). STUDY DESIGN: A prospective, single-arm, observational pilot study (Canadian Task Force classification II-1) was carried out at a specialized center for gynecologic endoscopy with 107 premenopausal women with menorrhagia secondary to DUB. NovaSure ablation was performed in 107 patients. Pictorial Blood loss Assessment Chart diary sampling was used to assess menstrual blood loss. Ablation was performed without any type of endometrial pretreatment. RESULTS: No intraoperative or postoperative complications were observed. Treatment time averaged 94 seconds; 65% of the patients reported amenorrhea. Hysterectomy was avoided in 97.2% of patients at 3-year follow-up. CONCLUSION: Long-term clinical results demonstrate that the NovaSure system is a safe and effective method for treatment of women with menorrhagia secondary to DUB, yielding high amenorrhea and success rates, with low re-treatment rates.     

宫腔镜手术治疗子宫内膜息肉的临床分析

目的　探讨宫腔镜手术治疗子宫内膜息肉的临床效果。方法　因子宫内膜息肉行各类宫腔镜手术 10 9例 ,其中绝经后子宫内膜息肉 15例、生育期子宫内膜息肉 94例。 10 9例中合并月经紊乱 84例、贫血 34例、痛经 16例、原发不孕 3例、继发不孕 2例。患者年龄 2 6～ 73岁 ,平均 (45± 9)岁 ;随访时间 3～ 2 2个月 ,平均 (12± 5 )个月。月经紊乱者在术前和术后分别填写月经失血图以评估月经血量。结果　 10 9例中 ,单纯息肉切除 35例 ,息肉切除同时浅层内膜切除 9例 ,息肉切除同时内膜切除 6 3例 ,息肉切除同时内膜剥除 2例。 84例月经紊乱者术后闭经 14例、阴道点滴出血 2 6例 ,其余 4 4例月经血量均较术前减少。 34例术前贫血患者 ,术后 1个月血红蛋白即恢复正常。 16例痛经者术后 7例症状消失、7例缓解、2例加重。 5例不孕者术后 4例妊娠。 15例绝经后患者术后无异常出血。结论　有月经改变且无生育要求者 ,息肉切除同时应行子宫内膜电切术 ,可避免息肉复发 ;需保留生育功能的患者 ,可行单纯息肉切除 ,如合并内膜息肉样增生 ,应同时行浅层内膜切除 ;绝经后患者 ,可行单纯息肉切除 ,如合并内膜息肉样增生 ,应同时行子宫内膜剥除。     

子宫腺肌症患者子宫次全切除术后的危险性探讨

目的 :探讨子宫腺肌症患者子宫次全切除术后的危险性 ,为临床子宫腺肌症患者手术方式的选择提供指导。方法 :对子宫腺肌症患者行子宫次全切除术标本的子宫体下切缘进行常规病理组织学检查。结果 :子宫体下切缘子宫内膜异位病灶 (切缘阳性 )的发生率为 12 %。切缘阳性子宫腺肌症患者的子宫肌层最大厚度、临床症状以及是否合并子宫内膜异位症与切缘阴性的子宫腺肌症患者差异无显著性 (P >0 .0 5)。但切缘阳性子宫腺肌症患者的宫体纵形长度明显小于切缘阴性者 (P <0 .0 5)。结论 :子宫腺肌症患者的病程较长 ,病变弥漫、痛经明显且时间较长、合并子宫内膜异位症可能是子宫体下切缘阳性的高危因素 ,手术时切口过高是子宫体下切缘阳性的直接因素。子宫腺肌症患者如年龄较大同时存在高危因素 ,则应行全子宫切除术 ,如行子宫次全切除术 ,切口位置应尽量低 ,而且应对子宫体下切缘行病理组织学检查     

Long-term follow-up after conservative surgery for rectovaginal endometriosis

OBJECTIVE: The purpose of this study was to evaluate long-term results in patients who received conservative surgical treatment for rectovaginal endometriosis. STUDY DESIGN: We analyzed the follow-up data for 83 women who underwent surgery for rectovaginal endometriosis. The inclusion criteria were age 20 to 42 years, moderate-to-severe pain symptoms, conservative treatment with retention of the uterus, and at least 1 ovary; the follow-up period was > or =12 months. Kaplan-Meier analysis and Cox regression were used to calculate recurrence rates. RESULTS: The cumulative rates of pain recurrence, clinical or sonographic recurrence, and new treatment were 28%, 34%, and 27%, respectively. The younger patients had the higher risk of recurrence. Pregnancy had protective effects against the recurrence of symptoms and a need for a new treatment. Patients who underwent bowel resection had fewer recurrences. CONCLUSION: Segmental resection and anastomosis of the bowel, when necessary, improves the outcome without affecting chances of conception. Higher recurrence rates in younger patients seems to justify a more radical treatment in this group of women.     

Repeat hysteroscopic surgery reduces the hysterectomy rate after endometrial and myoma resection

STUDY OBJECTIVE: To assess the efficacy of repeat transcervical resection of the endometrium (TCRE) in patients with dysfunctional uterine bleeding and myomas in whom primary resection failed. DESIGN: Retrospective analysis (Canadian Task Force classification III). SETTING: University hospital endoscopic unit. PATIENTS: Six hundred sixty-eight women. INTERVENTION: Repeat TCRE or transcervical resection of a myoma (TCRM). MEASUREMENTS AND MAIN RESULTS: Of 668 patients, 118 (17%) required repeat resection for the following reasons: pain (52, 44%), menorrhagia (39, 31%), myomas (15, 13%), perforation at the primary TCRE (6, 5%), and large fluid deficit during the procedure (6, 5%). Of 118 women undergoing repeat TCRE or TCRM, 33 (28%) eventually required hysterectomy due to pain (17, 48%), persistent bleeding (7, 27%), pain and bleeding (3, 10%), regrowth of myomas (3, 14%), and other reasons (3, 14%). CONCLUSION: Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate.     

Leiomyoma characteristics and risk of subsequent surgery after myomectomy.

OBJECTIVE: Evaluate the association between leiomyoma characteristics at myomectomy with subsequent surgery risk. METHODS: A population-based nested case control study from a cohort of women at a large HMO, identified as having had a myomectomy was performed; 82 cases had subsequent uterine surgery; 82 controls, frequency matched for age and date of first surgery, did not. Medical records were abstracted; follow-up was 18-128months. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated. RESULTS: Women without subserosal myomas were more likely to have a second surgery as compared to women with at least one subserosal myoma, aOR=4.1(95% CI 1.5-10.9). Size of myomas did not predict subsequent surgery in subanalyses by type of surgery. Number of leiomyomas was not predictive of a subsequent uterine surgery overall or in subgroup analyses. CONCLUSION: Myoma location, but not number or size, impacts the risk for subsequent leiomyoma uterine surgery.