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Marchand GJ, Masoud A, Grover S, King A, Brazil G, Ulibarri H, Parise J, Arroyo A, Coriell C, Moir C, Govindan M. First and second-generation endometrial ablation devices: A network meta-analysis. BMJ Open 2024; 14:e065966. [PMID: 38806429 PMCID: PMC11138282 DOI: 10.1136/bmjopen-2022-065966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/06/2023] [Indexed: 05/30/2024] Open
Abstract
OBJECTIVE First-generation and second-generation endometrial ablation (EA) techniques, along with medical treatment and invasive surgery, are considered successful lines of management for abnormal uterine bleeding (AUB). We set out to determine the efficacy of first and second-generation ablation techniques compared with medical treatment, invasive surgery and different modalities of the EA techniques themselves. DESIGN Systematic review and network meta-analysis using a frequentist network. DATA SOURCES We searched Medline (Ovid), PubMed, ClinicalTrials.gov, Cochrane CENTRAL, Web of Science, EBSCO and Scopus for all published studies up to 1 March 2021 using relevant keywords. ELIGIBILITY CRITERIA We included all randomised controlled trials (RCTs) that compared premenopausal women with AUB receiving the intervention of second-generation EA techniques. DATA EXTRACTION AND SYNTHESIS 49 high-quality RCTs with 8038 women were included. We extracted and pooled the data and then analysed to estimate the network meta-analysis models within a frequentist framework. We used the random-effects model of the netmeta package in R (V.3.6.1) and the 'Meta-Insight' website. RESULTS Our network meta-analysis showed many varying results according to specific outcomes. The uterine balloon ablation had significantly higher amenorrhoea rates than other techniques in both short (hydrothermal ablation (risk ratio (RR)=0.51, 95% CI 0.37; 0.72), microwave ablation (RR=0.43, 95% CI 0.31; 0.59), first-generation techniques (RR=0.44, 95% CI 0.33; 0.59), endometrial laser intrauterine therapy (RR=0.18, 95% CI 0.10; 0.32) and bipolar radio frequency treatments (RR=0.22, 95% CI 0.15; 0.31)) and long-term follow-up (microwave ablation (RR=0.11, 95% CI 0.01; 0.86), bipolar radio frequency ablation (RR=0.12, 95% CI 0.02; 0.90), first generation (RR=0.12, 95% CI 0.02; 0.90) and endometrial laser intrauterine thermal therapy (RR=0.04, 95% CI 0.01; 0.36)). When calculating efficacy based only on calculated bleeding scores, the highest scores were achieved by cryoablation systems (p-score=0.98). CONCLUSION Most second-generation EA systems were superior to first-generation systems, and statistical superiority between devices depended on which characteristic was measured (secondary amenorrhoea rate, treatment of AUB, patient satisfaction or treatment of dysmenorrhoea). Although our study was limited by a paucity of data comparing large numbers of devices, we conclude that there is no evidence at this time that any one of the examined second-generation systems is clearly superior to all others.
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Affiliation(s)
- Greg J Marchand
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Ahmed Masoud
- Fayoum University Faculty of Medicine, Fayoum, Egypt
| | | | - Alexa King
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Giovanna Brazil
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Hollie Ulibarri
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Julia Parise
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Amanda Arroyo
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Catherine Coriell
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Carmen Moir
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Malini Govindan
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
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Utility of anesthetic block for endometrial ablation pain: a randomized controlled trial. Am J Obstet Gynecol 2018; 218:225.e1-225.e11. [PMID: 29155035 DOI: 10.1016/j.ajog.2017.11.571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/30/2017] [Accepted: 11/09/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Second-generation endometrial ablation has been demonstrated safe for abnormal uterine bleeding treatment, in premenopausal women who have completed childbearing, in short-stay surgical centers and in physicians' offices. However, no standard regarding anesthesia exists, and practice varies depending on physician or patient preference and hospital policy and setting. OBJECTIVE The aim of this study was to evaluate whether local anesthetic, in combination with general anesthesia, affects postoperative pain and associated narcotic use following endometrial ablation. MATERIALS AND METHODS This was a single-center single-blind randomized controlled trial conducted in an academic-affiliated community hospital. A total of 84 English-speaking premenopausal women, aged 30 to 55 years, who were undergoing outpatient endometrial ablation for benign disease were randomized to receive standardized paracervical injection of 20 mL 0.25% bupivacaine (treatment group) or 20 mL normal saline solution (control group) upon completion of ablation. The study was designed to test a 40% 1-hour mean visual analog scale (VAS) pain score difference with an average standard deviation of 75% of both groups' mean VAS scores, using a 2-tailed test, a type I error of 5%, and statistical power of 80%. A sample of 36 patients per study group was required. Assuming a 15% attrition rate, the study enrolled 42 patients per study arm randomized in blocks of 2 (84 total). Two-tailed cross-tabulations with Fisher exact significance values where appropriate and Student t tests were used to compare patient characteristics. Backward stepwise regressions were conducted to control for confounding. RESULTS Between April 2016 and February 2017, a total of 108 women scheduled for endometrial ablation were screened (refusals, n = 21; ineligible, n = 3) to determine whether there were meaningful differences in postoperative VAS pain scores and postoperative narcotic use. Of the 84 randomized women, 2 age-ineligible women were excluded. Intent-to-treat analyses included 1 incorrect randomization (in which the provider consciously decided to provide analgesia regardless of the protocol, after which the provider was excluded from further study participation) and 3 women having no ablation because of operative difficulties. Three were lost to second-day follow-up. Treatment group patients (n = 41) experienced 1.3 points lower 1-hour postoperative VAS pain scores than the control group (n = 41, P = .02). The difference diminished by 4 hours (P = .31) and was negligible by 8 hours (P = .62). Treatment group patients used 3.6 less morphine equivalents of postoperative pain medication (P = .05). Regression analyses controlled for confounding reduced the 1-hour postoperative treatment group pain score difference to 0.8 (confidence interval [CI], -0.6 to 0.1) but slightly increased the average postoperative morphine equivalents to 3.7 (CI, -6.8 to -0.7). CONCLUSION This randomized controlled trial found that local anesthetic with low risk for complications, used in conjunction with general anesthesia, decreased postoperative pain at 1 hour and significantly reduced postoperative narcotic use following endometrial ablation. Further research is needed to determine whether the study results are generalizable and whether post procedure is the best time to administer the paracervical block to decrease endometrial ablation pain.
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Munro MG. Endometrial ablation. Best Pract Res Clin Obstet Gynaecol 2017; 46:120-139. [PMID: 29128205 DOI: 10.1016/j.bpobgyn.2017.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
Endometrial ablation (EA) includes a spectrum of procedures performed with or without hysteroscopic direction, designed to destroy the endometrium for the treatment of the symptom of heavy menstrual bleeding (HMB) secondary to a spectrum of causes, but most commonly those that are endometrial in origin (AUB-E) or ovulatory disorders (AUB-O). Resectoscopic endometrial ablation (REA) is often mistakenly referred to as the "first generation" technique, while proprietary devices that do not use the resectoscope (nonresectoscopic EA or NREA) are often misperceived as "second generation" devices. Indeed, the origins of NREA date back to the late 19th century with the use of steam, and the early and mid 20th century, when radiofrequency and cryotherapy based NREA techniques were published - long before the resectoscope was used and reported. The NREA devices have also been mislabeled as "global", a misleading term borrowed from the marketing departments of device manufacturers - there is no device that predictably treats the entire endometrium. Consequently, none can be construed as being "global". Instead, EA is a procedure designed for women as an alternative to hysterectomy, or, perhaps, medical therapy, when future fertility is no longer desired. Women who select EA should anticipate a relatively low risk procedure that will likely reduce their HMB to normal levels or less. This paper will review the spectrum of EA techniques and devices, their clinical outcomes and adverse events, and explore their value compared to hysterectomy and selected medical therapies.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, United States.
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Di Spiezio Sardo A, Spinelli M, Zizolfi B, Nappi C. Ambulatory management of heavy menstrual bleeding. ACTA ACUST UNITED AC 2015; 12:35-43. [PMID: 26696502 DOI: 10.2217/whe.15.80] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Heavy menstrual bleeding (HMB) has significant adverse effects on the quality of life of many women, placing an economic burden on both health services and society at large. Thus, it is essential that all women with HMB have easy access to the proper diagnostic and therapeutic work-up in an outpatient fashion, avoiding the more time-consuming inpatient management. This new outpatient approach for HMB is one of the latest development of gynecological practice and can offer both diagnostic and therapeutic procedures. This manuscript aims to show the current possibilities of the modern management of HMB, which can be safely and effectively accomplished in the outpatient setting: global and directed endometrial biopsy, levonorgestrel intrauterine system insertion as well as minimally invasive surgical procedures (encompassing a variety of operative hysteroscopic procedures and second-generation endometrial ablation) are described below.
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Affiliation(s)
- Attilio Di Spiezio Sardo
- Department of Neurosciences & Reproductive Sciences, University of Naples Federico II, Naples, Italy
| | - Marialuigia Spinelli
- Department of Neurosciences & Reproductive Sciences, University of Naples Federico II, Naples, Italy
| | - Brunella Zizolfi
- Department of Neurosciences & Reproductive Sciences, University of Naples Federico II, Naples, Italy
| | - Carmine Nappi
- Department of Neurosciences & Reproductive Sciences, University of Naples Federico II, Naples, Italy
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Endometrial Ablation: Normal Imaging Appearance and Delayed Complications. AJR Am J Roentgenol 2015; 205:W451-60. [DOI: 10.2214/ajr.14.13960] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Madsen AM, El-Nashar SA, Hopkins MR, Khan Z, Famuyide AO. Endometrial ablation for the treatment of heavy menstrual bleeding in obese women. Int J Gynaecol Obstet 2013; 121:20-3. [PMID: 23312401 DOI: 10.1016/j.ijgo.2012.10.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/17/2012] [Accepted: 12/11/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of endometrial ablation (EA) among obese versus non-obese women. METHODS A retrospective cohort study of 666 women who underwent EA at the Mayo Clinic, Rochester, USA, between January 1, 1998, and December 31, 2005, was conducted. Obesity was defined as a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of 30 or above. Outcome measures included treatment failure and amenorrhea. Regression models were used to compare outcomes and adjust for known confounders. RESULTS The mean BMI was 29.6±7.7; 263 women (39.5%) were classified as obese. No difference was observed in treatment failure at 5 years between the obese and non-obese cohorts (11.6% vs 9.7%) with an adjusted hazard ratio of 0.96 (95% confidence interval [CI], 0.60-1.53; P=0.878). The crude 12-month amenorrhea rate was higher among non-obese than obese women (24.3% vs 17.5%); however, this difference was not significant after adjusting for known predictors of amenorrhea. The odds ratio was 1.28 (95% CI, 0.75-2.19; P=0.366). Adverse events were rare and comparable between the cohorts. CONCLUSION The use of EA is a safe and effective option for women with obesity.
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Affiliation(s)
- Annetta M Madsen
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN 55905, USA
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Laberge PY. NovaSure(): the bipolar radiofrequency endometrial ablation system for dysfunctional uterine bleeding. ACTA ACUST UNITED AC 2012; 2:687-93. [PMID: 19803821 DOI: 10.2217/17455057.2.5.687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The bipolar radiofrequency endometrial ablation system (NovaSure()) has been developed to treat women suffering from menorrhagia due to dysfunctional uterine bleeding. This technology allows for a customized, controlled, contoured endometrial ablation, without the need for hysteroscopic visualization and endometrial pretreatment. Average treatment time is 90 s. Active bleeding, at the time of treatment, is not found to be a limiting factor for the use of this technology. Technical aspects of the bipolar radiofrequency ablation procedure are described and summarized in this article. The safety features employed, combined with a high level of effectiveness and patient satisfaction, qualifies this system for consideration as a logical alternative to hysterectomy as well as an alternative to hysteroscopic endometrial ablation.
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Affiliation(s)
- Philippe Y Laberge
- Department of Obstetrics & Gynaecology, Laval University, 2705 Boul. Laurier S-768, Quebec City, Quebec, G1V 4G2, Canada.
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Basinski CM, Price P, Burkhart J, Johnson J. Safety and Effectiveness of NovaSure ® Endometrial Ablation After Placement of Essure ® Micro-Inserts. J Gynecol Surg 2012; 28:83-88. [PMID: 24761128 DOI: 10.1089/gyn.2011.0061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: In-office NovaSure® after Essure® is a clinical paradigm for which physicians are seeking information. A PubMed search (July 2011) revealed no peer-reviewed articles describing this treatment sequence. To address the paucity of data on this topic, patients who had undergone Essure followed by NovaSure in a private practice office between July 1, 2008 and December 31, 2009 were evaluated. The objective was to evaluate safety and feasibility of in-office NovaSure after Essure, and to determine if the effectiveness of either procedure was altered by this treatment sequence. Design: This was a retrospective cohort study of 117 women (ages 24-52). Methods: Patients underwent Essure followed by NovaSure in two in-office sessions, separated by a median of 14 days. All patients had menorrhagia and desired permanent sterilization. A postprocedure patient questionnaire was administered to assess satisfaction and perceived effectiveness. Results: Among patients who underwent Essure followed by NovaSure, 83/117 (71%) returned for a 3-month hysterosalpingogram (HSG). Satisfactory placement and tubal occlusion were noted in 79/83 (95%) of these patients. Amenorrhea or spotting was observed in 72/97 (74%) of patients, 22/97 (23%) reported a satisfactory decrease in menstrual flow, and 3/97 (3%) reported ablation failure. Essure followed by NovaSure did not decrease the effectiveness of either procedure, and no adverse events were attributed to the combination of the two procedures. Patients reported high levels of satisfaction with both procedures. Conclusions: In women seeking permanent birth control and menorrhagia reduction, in-office Essure followed by NovaSure appeared to be safe, effective, and associated with high patient satisfaction. (J GYNECOL SURG 28:1).
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Skensved H. Global–local anaesthesia: combining paracervical block with intramyometrial prilocaine in the fundus significantly reduces patients' perception of pain during radio-frequency endometrial ablation (Novasure®) in an office setting. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s10397-011-0709-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bergeron ME, Ouellet P, Bujold E, Cote M, Rhéaume C, Lapointe D, Beaudet C, Lemyre M, Laberge P. The Impact of Anesthesia on Glycine Absorption in Operative Hysteroscopy. Anesth Analg 2011; 113:723-8. [DOI: 10.1213/ane.0b013e31822649d4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kalkat RK, Cartmill RSV. NovaSure endometrial ablation under local anaesthesia in an outpatient setting: An observational study. J OBSTET GYNAECOL 2011; 31:152-5. [DOI: 10.3109/01443615.2010.538772] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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12
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NovaSure impedance controlled system for endometrial ablation: The experience of the first UK reference centre. J OBSTET GYNAECOL 2009; 29:419-22. [DOI: 10.1080/01443610902932291] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Practical Tips for Office Hysteroscopy and Second-Generation “Global” Endometrial Ablation. J Minim Invasive Gynecol 2009; 16:384-99. [DOI: 10.1016/j.jmig.2009.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Revised: 03/23/2009] [Accepted: 04/03/2009] [Indexed: 11/19/2022]
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Vilos GA, Edris F. Second-generation endometrial ablation technologies: the hot liquid balloons. Best Pract Res Clin Obstet Gynaecol 2007; 21:947-67. [PMID: 17543585 DOI: 10.1016/j.bpobgyn.2007.03.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hysteroscopic endometrial ablation (HEA) was introduced in the 1980s to treat menorrhagia. Its use required additional training, surgical expertise and specialized equipment to minimize emergent complications such as uterine perforations, thermal injuries and excessive fluid absorption. To overcome these difficulties and concerns, thermal balloon endometrial ablation (TBEA) was introduced in the 1990s. Four hot liquid balloons have been introduced into clinical practice. All systems consist of a catheter (4-10mm diameter), a silicone balloon and a control unit. Liquids used to inflate the balloons include internally heated dextrose in water (ThermaChoice, 87 degrees C), and externally heated glycine (Cavaterm, 78 degrees C), saline (Menotreat, 85 degrees ) and glycerine (Thermablate, 173 degrees C). All balloons require pressurization from 160 to 240 mmHg for treatment cycles of 2 to 10 minutes. Prior to TBEA, preoperative endometrial thinning, including suction curettage, is optional. Several RCTs and cohort studies indicate that the advantages of TBEA include portability, ease of use and short learning curve. In addition, small diameter catheters requiring minimal cervical dilatation (5-7 mm) and short duration of treatment cycles (2-8 min) allow treatment under minimal analgesia/anesthesia requirements in a clinic setting. Following TBEA serious adverse events, including thermal injuries to viscera have been experienced. To minimize such injuries some surgeons advocate the use of routine post-dilatation hysteroscopy and/or ultrasonography to confirm correct intrauterine placement of the balloon prior to initiating the treatment cycle. After 10 years of clinical practice, TBEA is thought to be the preferred first-line surgical treatment of menorrhagia in appropriately selected candidates. Economic modeling also suggested that TBEA may be more cost-effective than HEA.
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Affiliation(s)
- George A Vilos
- Department of Obstetrics and Gynecology, The University of Western Ontario, London, ON, Canada.
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Iavazzo C, Salakos N, Bakalianou K, Vitoratos N, Vorgias G, Liapis A. Thermal balloon endometrial ablation: a systematic review. Arch Gynecol Obstet 2007; 277:99-108. [PMID: 17805554 DOI: 10.1007/s00404-007-0449-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 08/13/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of our study is to review the role of thermal balloon endometrial ablation (TBEA) as an alternative in treating abnormal uterine bleeding. METHODS Articles relevant to our review and relevant references from the initially identified articles on the field that were archived by May 2007, were retrieved from Pubmed. RESULTS Success rates ranged from 83 up to 94%, with patient's satisfaction ranging from 57 up to 94%. Persisted menorrhagia could reach 17% in some studies. CONCLUSION TBEA is an effective alternative method used in the treatment of menorrhagea which results in a significant reduction in menstrual bleeding and high satisfaction rates. However, a longer follow-up is required to determine the role of such a treatment.
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Affiliation(s)
- C Iavazzo
- Department of Gynecology, METAXA Cancer Hospital, Piraeus, Greece.
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Hopkins MR, Creedon DJ, El-Nashar SA, Brown DL, Good AE, Famuyide AO. Radiofrequency global endometrial ablation followed by hysteroscopic sterilization. J Minim Invasive Gynecol 2007; 14:494-501. [PMID: 17630170 DOI: 10.1016/j.jmig.2007.01.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 01/05/2007] [Accepted: 01/14/2007] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To describe the feasibility of performing Essure hysteroscopic sterilization immediately after NovaSure global endometrial ablation (GEA). DESIGN Descriptive feasibility study (Canadian Task Force classification III). SETTING Midwestern United States academic medical center. PATIENTS Twenty-five women (aged 35-49 years) with menorrhagia who elected GEA treatment and requested concurrent permanent sterilization. INTERVENTIONS NovaSure GEA followed immediately by Essure hysteroscopic sterilization. Patients returned 3 months after the procedure for hysterosalpingography (HSG) to document tubal occlusion. MEASUREMENTS AND MAIN RESULTS The inserts were placed successfully in all 25 patients; 21 returned for 3-month follow-up HSG, as recommended. Bilateral tubal occlusion was documented at 3 months in 19 patients (90%) and unilateral occlusion in 2 patients. Six-month postprocedural HSG in these 2 patients documented bilateral tubal occlusion. Hysterosalpingography was not performed in 4 patients. In all 21 patients with appropriate follow-up, complete occlusion was documented, and the ability to perform or interpret HSG was not affected by endometrial ablation. CONCLUSION Essure hysteroscopic sterilization can be safely performed after NovaSure GEA. Intrauterine synechiae do not appear to adversely affect the ability to perform HSG at 3 months or to document tubal occlusion.
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Affiliation(s)
- Matthew R Hopkins
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Munro MG. Management of Heavy Menstrual Bleeding: Is Hysterectomy the Radical Mastectomy of Gynecology? Clin Obstet Gynecol 2007; 50:324-53. [PMID: 17513922 DOI: 10.1097/grf.0b013e31804a82e2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Both hysterectomy for heavy menstrual bleeding and radical mastectomy for breast cancer are steeped in the history of surgery and have recently been challenged as being too radical for the disorder at hand. Radical mastectomy has largely been replaced with local removal of the tumor with subsequent radiation and/or chemotherapy. Alternatives to hysterectomy include a number of medical interventions, most notably intrauterine progestin-releasing systems, and endometrial ablation, a procedure that has a relatively high success rate and one that is now feasible for many women in an office or procedure room setting. However, although radical mastectomy rates have dropped precipitously, hysterectomy rates, at least in the United States remain relatively stable. Determining the proportion of hysterectomies that are done for heavy menstrual bleeding is difficult, largely because of coding issues, so it is difficult to measure the impact of new medical and minimally invasive surgical procedures. Nevertheless, it seems clear that many women are not exposed to the plethora of options to hysterectomy, a fact that may reflect a number of issues that may include training, skill, and financial incentives or disincentives. Clearly, options to hysterectomy are not a panacea, but if women are empowered to select from all of the options available, the rate of hysterectomy for bleeding should decrease while maintaining, or even enhancing the patient's satisfaction with care.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Kaiser Foundation Hospitals, Los Angeles Medical Center, Los Angeles, CA 90027, USA.
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Abstract
The Novasure endometrial ablation system consists of a single-use device and a radiofrequency controller. It is a three-dimensional, triangular-shaped bipolar ablation device. The generator functions at 500 kHz and has a power cut-off limit set at a tissue impedance of 50 Ohms. The self-terminating procedure is based on tissue impedance or time. A cavity assessment system works to detect perforations in the uterine cavity. No pretreatment is necessary. Randomized controlled trials have shown that the Novasure system has an amenorrhoea rate of 44-56% at 1-year follow-up, and the 5-year results of a randomized trial will be published shortly. Prospective observational studies show even higher amenorrhoea rates of up to 58-75% up to 5-year follow-up. Hysterectomy rates in the prospective trial were very low (4%). In summary, the Novasure endometrial ablation system is an effective second-generation ablation technique, resulting in a high percentage of amenorrhoea.
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Affiliation(s)
- Marlies Y Bongers
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, 5500 MB, Veldhoven, The Netherlands.
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Fulop T, Rákóczi I, Barna I. NovaSure impedance controlled endometrial ablation: Long-term follow-up results. J Minim Invasive Gynecol 2007; 14:85-90. [PMID: 17218236 DOI: 10.1016/j.jmig.2006.09.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 08/25/2006] [Accepted: 09/02/2006] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE A 7-year follow-up evaluation of the safety, efficacy, and long-term outcome of endometrial ablation when using the NovaSure system in patients with menorrhagia secondary to abnormal uterine bleeding (AUB). DESIGN Prospective, single-arm study (Canadian Task Force classification II-1). SETTING St. Imre Teaching Hospital, Budapest, Hungary. PATIENTS Seventy-five premenopausal women with menorrhagia secondary to AUB. INTERVENTIONS Endometrial ablation using the NovaSure System without the use of endometrial pretreatment. MEASUREMENTS AND MAIN RESULTS Loss of menstrual blood was measured using pictorial blood loss assessment chart diaries. Treatment times, complications, and rate of surgical re-interventions were recorded. No intra or postoperative complications were noted. Median follow-up period at the time was 7.8 years (range 6-8.6 years). The proportion of patients with fewer than 7 and 7 or more years of follow-up was 28.8% and 71.2%, respectively. The median treatment time was 92 seconds (range 40-120 seconds). At 7-year follow-up, 97.1% of evaluable patients reported amenorrhea. However, all patients (100%, actuarial rate: 97% with 95% CI [83%-100%]) experienced a successful reduction in bleeding to normal levels or less. Six of 75 patients underwent hysterectomy, and one of 75 had a repeat ablation representing a total of 92% (95% CI: 83%-96%) avoidance of additional surgery during the follow-up period. CONCLUSIONS Clinical results demonstrate that the use of NovaSure System is safe and effective, with a low rate of surgical re-intervention at 7-year follow-up.
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Affiliation(s)
- Tamas Fulop
- Department of Obstetrics and Gynecology, St. Imre Teaching Hospital, Budapest, Hungary.
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Abstract
Endometrial ablation (EA) is targeted destruction of the endothelial surface of the uterine cavity. The procedure was originally designed as a less invasive alternative to hysterectomy for the symptom of heavy menstrual bleeding unrelated to structural pathology of the uterus, that was not responsive to medical therapy. More recently it has become apparent that the procedure can be performed in the presence of submucous leiomyomas, providing they meet a number of size and location criteria. The first EA serie as published in Germany in the 1930s, but the procedure did not attract much attention until the latter part of the 20th century. Currently, EA can be performed under endoscopic direction with the neodymium:yttrium alumnum garnet laser, with a radiofrequency resectoscope, or with an expanding array of nonresectoscopic EA systems. It is apparent that most but not all of the complications associated with resectoscopic endometrial ablation are eliminated with nonresectoscopic endometrial ablation, but serious morbidity has been reported with all of the newer systems to date. Success and patient satisfaction seem to be enduring in the majority of well-selected patients treated in clinical trials, but repeat surgery, usually hysterectomy, is performed in 25% to 40% by 5 years after surgery. Increased efficiencies should be realized if the procedure could be moved to an office setting.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Kaiser Foundation Hospitals, Los Angeles Medical Center, Los Angeles, California 90027, USA.
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Sabbah R, Desaulniers G. Use of the NovaSure Impedance Controlled Endometrial Ablation System in patients with intracavitary disease: 12-month follow-up results of a prospective, single-arm clinical study. J Minim Invasive Gynecol 2006; 13:467-71. [PMID: 16962534 DOI: 10.1016/j.jmig.2006.04.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2005] [Revised: 04/05/2006] [Accepted: 04/06/2006] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To assess the safety and effectiveness of the NovaSure Impedance Controlled Endometrial Ablation System for the treatment of excessive uterine bleeding in premenopausal and postmenopausal women with intracavitary disease (polyps or myomas) up to 3 cm. DESIGN Prospective, single-arm study. (Canadian Task Force Classification II-2.) SETTING Academic medical center. PATIENTS This clinical study was conducted in 65 women with menometrorrhagia with confirmed (type I and II) submucous myomas up to 3 cm with and without polyps. INTERVENTION Patients were treated with the NovaSure System and received no hormonal or mechanical pretreatment to thin the endometrial lining or as a uterine pathologic condition shrinking agent. MEASUREMENTS AND MAIN RESULTS All patients were diagnosed with intracavitary disease during office hysteroscopy. Patients completed menstrual questionnaires at the initial screening and at 1 year after treatment. Twelve-month results demonstrated that the NovaSure System was effective in reducing excessive uterine blood loss. Success (defined as reduction to normal bleeding) was observed in 95% (95% CI: 86%-99%) of patients, with 69% (95% CI: 56%-80%) reporting amenorrhea at 1 year after treatment. The median treatment time (time of energy delivery) was 78 seconds (range 61-120 seconds). All patients underwent the procedure under local or intravenous sedation. No intraoperative or postoperative adverse events were reported. There was a significant decrease in premenstrual symptoms and dysmenorrhea at 12 months after the procedure. Ninety-five percent (95% CI: 86%-99%) of patients were satisfied with the procedure. CONCLUSION Clinical results of this study demonstrate that the NovaSure System is safe and effective in treatment of patients with menometrorrhagia caused by intracavitary disease up to 3 cm.
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Affiliation(s)
- Robert Sabbah
- University of Montreal, Hôpital Sacré Coeur, Montreal, Quebec, Canada.
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Amso NN. Clinical and health service implications of second generation endometrial ablation devices. Curr Opin Obstet Gynecol 2006; 18:457-63. [PMID: 16794429 DOI: 10.1097/01.gco.0000233943.74672.2e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review evaluates the current evidence on the efficacy, safety and cost-effectiveness of the ever-increasing number of second-generation endometrial ablation devices. RECENT FINDINGS The literature covered by this review includes (1) evidence on long-term benefit, avoidance of hysterectomy and improvement in quality of life, (2) applicability of these techniques in the outpatient environment under local or no anaesthesia, (3) frequency and nature of early and delayed complications associated with these devices, (4) impact on clinical practice and the health service, and (5) implications for research. SUMMARY Where appropriate, second-generation devices are rapidly becoming the first-line surgical choice for the management of heavy menstrual bleeding. This has both cost-savings and negative implications for the health service. There is also emerging evidence that improvement in quality of life is more relevant to women than amenorrhoea rates. What has come to light from this review is the lack of accurate data on adverse events rate, and the urgent need for a better appreciation of the frequency and nature of complications.
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Affiliation(s)
- Nazar N Amso
- Department of Obstetrics and Gynaecology, Wales College of Medicine, Cardiff University, University Hospital of Wales and Vale NHS Trust, Cardiff, UK.
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Sinha A, Clark JT, Gupta J. An update on second-generation devices for endometrial ablation. Expert Rev Med Devices 2005; 2:635-41. [PMID: 16293075 DOI: 10.1586/17434440.2.5.635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Menorrhagia is a very common problem. Hysterectomy has been the traditional surgical treatment of choice guaranteeing amenorrhoea. It is 100% effective but is associated with surgical complications, and is more costly in terms of economic impact and recovery time. Minimally invasive procedures to ablate the endometrium reduce complications and recovery time. The newer second-generation endometrial ablation devices negate the need for surgery under direct hysteroscopic vision, thus ensuring that the treatments are not operator dependent. However, they heavily rely on the device themselves to ensure safety and efficacy. There are a variety of these devices currently available on the market. The authors will review these devices and provide the evidence for their suitability in various settings.
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Affiliation(s)
- Anju Sinha
- Queen's Medical Centre, University Hospital NHS Trust, Derby Road, Nottingham, NG7 2UH, UK.
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Sambrook AM, Parkin DE. Endometrial ablation—A review of second generation techniques. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.rigp.2005.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
PURPOSE OF REVIEW This review evaluates the currently available evidence regarding resectoscopic endometrial ablation (REA) and the various nonresectoscopic endometrial ablation (NREA) techniques used for heavy menstrual bleeding. RECENT FINDINGS Laser endometrial ablation is now used infrequently, largely because of procedure time, but also because of the cost and training associated with the technique. REA can be performed in a wider spectrum of endometrial cavity configurations than NREA and, at least in expert hands, remains the gold standard. Each of the five available types of NREA device possesses advantages and disadvantages over the others with respect to variables such as treatment time, required cervical dilation, and size and configuration of the endometrial cavity. All provide acceptable results that are comparable to that of REA in expert hands. Serious complications seem to be less common with NREA, but uterine perforation and bowel or other visceral injury can still occur. When endometrial-ablation patients were followed for up to 5 years, repeat surgery rates ranged from 20 to 40%, thereby eroding both the direct and indirect treatment-related resource utilization. Levonorgestrel-releasing intrauterine devices demonstrate similar clinical and patient-satisfaction outcomes to endometrial ablation but can be inserted in the office and allow maintenance of fertility. SUMMARY Both REA and NREA provide at least short- to intermediate-term options to hysterectomy for patients with heavy menstrual bleeding and normal or near-normal endometrial cavities. Consequently, the ideal candidates are likely those who are within 5 years of menopause.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Kaiser Foundation Hospitals, Los Angeles Medical Center, Los Angeles, CA, USA.
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Solnik JM, Guido RS, Sanfilippo JS, Krohn MA. The impact of endometrial ablation technique at a large university women's hospital. Am J Obstet Gynecol 2005; 193:98-102. [PMID: 16021066 DOI: 10.1016/j.ajog.2004.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the effect of ThermaChoice uterine balloon system on the practice patterns of endometrial ablations performed at a large university-based teaching hospital. STUDY DESIGN A retrospective chart review was conducted of 226 patients who underwent endometrial ablation. Data were analyzed to determine any change in the type and rate of ablations performed since the introduction of second-generation technologies. Multivariate logistic regression models were used to estimate adjusted risk factors for subsequent admission. RESULTS A total of 72.1% of all cases were performed with the ThermaChoice uterine balloon. The postoperative admission rate was significantly higher after a balloon procedure (13.7% versus 3.1%, P=.02), with a 10.6% overall incidence of admission. Adjusting for confounding variables, more women were admitted after a balloon procedure, compared with women undergoing hysteroscopic ablation (odds ratio 5.0; 95% CI: 1.1, 22). CONCLUSION Second-generation endometrial ablation technologies represent frequently utilized and proficient treatment modalities for dysfunctional uterine bleeding. Notwithstanding their facilitative design, clinicians should not lose sight of potential limitations of these new procedures.
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Affiliation(s)
- Jonathon M Solnik
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, Pittsburgh, PA, USA.
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Baskett TF, Clough H, Scott TA. NovaSure Bipolar Radiofrequency Endometrial Ablation: Report of 200 Cases. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2005; 27:473-6. [PMID: 16100642 DOI: 10.1016/s1701-2163(16)30530-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review the perioperative complications and short-term outcome in women undergoing endometrial ablation for menorrhagia using the NovaSure bipolar radiofrequency impedance-controlled system. METHODS We conducted a prospective observational study of endometrial ablation using the NovaSure system in 200 women with menorrhagia not amenable to medical management. RESULTS Of the 200 women treated, 146 have been observed for 1 to 4 years with the following outcomes related to menstrual bleeding: amenorrhea 43.1%, light bleeding 41.8%, normal bleeding 4.1%, and heavy bleeding 11%. Twelve of the 146 women (8.2%) required repeat surgical treatment: hysterectomy in 10 cases and repeat ablation in 2. In the 200 cases, 1 laparoscopy was performed because of uterine perforation at the time of pretreatment hysteroscopy, and 2 patients required antibiotic therapy for postoperative endomyometritis. Of the women observed for 1 to 4 years, 81.5% felt the procedure was successful, and 97.3% would recommend the procedure to a friend. CONCLUSION Endometrial ablation using the NovaSure system is a simple technique in the normal uterine cavity, which can be performed under local anaesthesia and conscious sedation. The complication rate is low, and the short-term satisfaction and results are good.
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Affiliation(s)
- Thomas F Baskett
- Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada
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Clark TJ, Gupta JK. Outpatient thermal balloon ablation of the endometrium. Fertil Steril 2004; 82:1395-401. [PMID: 15533366 DOI: 10.1016/j.fertnstert.2004.04.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2004] [Revised: 04/30/2004] [Accepted: 04/30/2004] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the feasibility and potential efficacy of thermal balloon ablation of the endometrium in the outpatient setting without the need for general anesthesia or conscious sedation. DESIGN Prospective observational study. SETTING Outpatient hysteroscopy clinic in a university-affiliated teaching hospital. PATIENT(S) Fifty-three consecutively recruited women with menorrhagia that was unresponsive to medical treatment. INTERVENTION(S) Thermal balloon endometrial ablation using local anesthetic without conscious sedation. MAIN OUTCOME MEASURE(S) Procedure feasibility, change in menstrual symptoms, and patient satisfaction and quality of life (Menorrhagia Utility Scale and EuroQol) at 6-month follow-up. RESULT(S) Thermal balloon ablation was successfully completed in 50 (94%) of 53 women. The three failed procedures consisted of one case in which the woman could not tolerate the procedure because of severe discomfort, one case of equipment failure, and one case in which the balloon catheter could not be inserted into the uterine cavity. Completed outcome questionnaires were returned by 49 (98%) of 50 treated women. Improvement in menstrual loss was experienced by 39 (80%) of 49 women, and satisfaction with the outcome of treatment on menstrual symptoms was reported by 33 (67%) of 49 women. Significantly higher condition-specific quality-of-life scores were associated with treatment satisfaction. CONCLUSION(S) Thermal balloon ablation of the endometrium is feasible in the outpatient setting. Improvement in menstrual symptoms and satisfaction with the outcome of treatment appear to be comparable to published inpatient data. Further studies are required to determine the cost-effectiveness of outpatient compared with inpatient thermal balloon therapy.
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Affiliation(s)
- Thomas Justin Clark
- Academic Department of Obstetrics and Gynaecology, Birmingham Women's Hospital, Birmingham, United Kingdom.
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Gallinat A. NovaSure impedance controlled system for endometrial ablation: three-year follow-up on 107 patients. Am J Obstet Gynecol 2004; 191:1585-9. [PMID: 15547528 DOI: 10.1016/j.ajog.2004.05.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Abstract
Endometrial ablation is defined as the elimination of the endometrium by thermal energy or resection. It was introduced in the 1980s as an alternative to hysterectomy to those patients with abnormal uterine bleeding and benign pathology who are unable or unwilling to tolerate traditional therapies. This article explores various endometrial ablation techniques.
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Affiliation(s)
- George A Vilos
- Department of Obstetrics and Gynecology, University of Western Ontario, St. Joseph's Health Care, Room L111, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada.
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