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.