Hysteroscopic endometrial ablation using free heated saline for the treatment of menorrhagia

A Prospective, Multicenter, Pivotal Trial to Evaluate the Safety and Effectiveness of the AEGEA Vapor Endometrial Ablation System

STUDY OBJECTIVE

To evaluate the safety and effectiveness of the AEGEA Vapor System (Aegea Medical System, Menlo Park, CA) for the treatment of heavy menstrual bleeding (HMB).

DESIGN

A prospective, multicenter, single-arm, open-label, clinical trial. Follow-up assessments were conducted at 24 hours; 2 weeks; and 3, 6, and 12 months after the endometrial ablation procedure (Canadian Task Force Classification II-1).

SETTING

A private practice and outpatient and hospital settings at 15 sites in the United States, Canada, Mexico, and the Netherlands.

PATIENTS

One hundred fifty-five premenopausal women aged 30 to 50years with HMB as determined by a pictorial blood loss assessment score ≥150. Preoperative evaluation included ultrasound, sonohysterography or hysteroscopy, and endometrial biopsy. Screening inclusion allowed treatment of up to 12-cm uterine sound lengths and nonobstructing myomata.

INTERVENTIONS

Endometrial ablation (120-second treatment time) was performed under varying anesthesia regimens using the vapor system from September 2014 to May 2015.

MEASUREMENTS AND MAIN RESULTS

The primary effectiveness end point was the reduction of menstrual blood loss to a pictorial blood loss assessment score ≤75. Success was judged based on the Food and Drug Administration's objective performance criteria, derived from the success rates of the first 5 global endometrial ablation pivotal clinical trials. The secondary effectiveness end points included quality of life and patient satisfaction as assessed using the Menorrhagia Impact Questionnaire and the Aberdeen Menorrhagia Severity Score as well as the need for surgical or medical intervention to treat abnormal bleeding at any time within the first 12 months after treatment. All adverse events, including device- and procedure-related events, were recorded. At 12 months, the primary effectiveness end point was achieved in 78.7% of subjects exceeding the OPC (p = .0004); 90.8% of subjects were satisfied or very satisfied with the treatment. Ninety-nine percent of subjects showed improvement in quality of life scores with an average decrease in the Menorrhagia Impact Questionnaire score by 8.1, 72% had less dysmenorrhea, and 85% of women whose sex lives were affected by their menses reported improvement in their sex lives. There were no reported serious adverse device effects or any reported serious adverse events that were procedure related.

CONCLUSION

The AEGEA Vapor System is a safe, effective, and minimally invasive option for performing in-office endometrial ablation under minimal anesthesia for the purpose of treating women who suffer from HMB.

Percutaneous selective myoablation in plastic surgery

A new technique in aesthetic plastic surgery termed "myoablation" is described. Thermal energy is applied via the percutaneous route for ablation of selected facial muscles to modify the facial dynamics. Myoablation was found to be useful in ameliorating noticeable frown wrinkles caused by muscular hyperactivity. A series of 30 patients underwent myoablation as the sole procedure with encouraging results. In 80% of the cases, good to excellent aesthetic results were achieved. This report presents the electrophysiologic bases, technique, animal experiments, and initial clinical experience of myoablation.

Does hydrothermal ablation avoid hysterectomy? Long-term follow-up

OBJECTIVE

We sought to assess the long-term success rate of the HydroThermAblator system (HTA).

STUDY DESIGN

We conducted a retrospective cohort study of 376 patients who underwent HTA at our hospital during an 8-year period, following case note review and distribution of a validated menorrhagia questionnaire.

RESULTS

The mean age of patients was 43 years. Operative complications included 3 women (0.8%) who experienced intraoperative burns. Of the 248 (66%) returned questionnaires, satisfaction rates were high at 77%. The amenorrhea rate was 38%, with a further 37% of women reporting a substantial decrease in their blood loss. In all, 29 (11%) women underwent subsequent hysterectomy for persistent menorrhagia or dysmenorrhea. Younger women had a significantly higher chance of proceeding to subsequent (P < .05) hysterectomy.

CONCLUSION

This study confirms the long-term patient satisfaction with HTA and that the overall probability of proceeding to subsequent hysterectomy over 8 years was only 11%.

The Hydro ThermAblator

The Hydro ThermAblator system is a unique approach to endometrial ablation, employing constant direct visual control via hysteroscopy combined with a 'no-touch' gravity flow of heated saline that treats the entire endometrial surface regardless of its topography. The automated controller helps to ensure reproducible results without the necessity for high operator skill. The system employs a safety feature that monitors the fluid level constantly within a closed system, so that loss of fluid through unsuspected uterine perforation occurring during dilatation can be diagnosed even though it may not be visually apparent to the operator. Results as judged by patient satisfaction, amenorrhoea rates and/or return to normal menstrual flow are excellent.

An in vitro uterine perfusion model for investigating endometrial cryoablation

STUDY OBJECTIVES

To build a simple in vitro uterine perfusion model for investigating the clinical effectiveness of endometrial ablation.

DESIGN

Comparative laboratory and in vivo study (Canadian Task Force classification II-2).

SETTING

University teaching hospital.

PATIENTS

Women undergoing hysterectomy for menorrhagia with uteri of normal shape and size.

INTERVENTIONS

A single 5-minute freeze, followed by an active thaw was applied to the endometrial cavity of uteri in vivo and in the in vitro perfusion model.

MEASUREMENTS AND MAIN RESULTS

Endometrial/myometrial temperature change was measured continuously during the cryosurgical procedure. Depth of cell death was measured using nicotinamide adenine dinucleotide diaphorase enzyme assay. There was no significant difference in temperature change and depth of cell death in endometrial/myometrial tissue between in vivo and in vitro perfusion experiments.

CONCLUSIONS

The in vitro perfusion model described is a useful tool for investigating endometrial cryoablation and has potential for investigating and developing other intrauterine surgical modalities.

Indications and options for endometrial ablation

Endometrial ablation is an effective therapeutic option for the management of menorrhagia in properly selected patients. Hysteroscopic and non-hysteroscopic techniques offer similar rates of symptom relief and patient satisfaction.

Ex vivo investigation of the use of hydrothermal energy to induce chondrocyte necrosis in articular cartilage of the metacarpophalangeal and metatarsophalangeal joints of horses

OBJECTIVE

To evaluate the use of hydrothermal ablation of articular cartilage for arthrodesis in horses through investigation of the effects of joint lavage with physiologic saline (0.9% NaCI) solution (80 degrees C) for various treatment times on chondrocyte viability in the articular cartilage of the metacarpophalangeal and metatarsophalangeal joints of cadaveric horse limbs. Sample Population-7 pairs of metacarpophalangeal and 8 pairs of metatarsophalangeal joints from 8 Thoroughbreds.

PROCEDURE

The horses were euthanatized for reasons unrelated to musculoskeletal disease. On a random basis, 1 joint of each pair underwent intra-articular lavage for 5, 10, or 15 minutes with heated saline solution (80 degrees C); the other joint underwent sham treatment of similar duration with saline solution at 22 degrees C (control). Cartilage samples from the distal articular surface of metacarpus III (or metatarsus III), the proximal surface of the proximal phalanx, and the lateral and medial proximal sesamoid bones were assessed for chondrocyte viability via confocal microscopy and viability staining following enzymatic digestion.

RESULTS

Compared with the control joints, findings of both viability assays indicated that the percentage of sites containing viable chondrocytes in heat-treated joints was decreased. Treatment hazard ratios of 0.048 (confocal microscopy) and 0.2 (digestion assay) were estimated. Histologically, periarticular soft tissues had minimal detrimental effects after heat treatment.

CONCLUSIONS AND CLINICAL RELEVANCE

Ex vivo intra-articular lavage with saline solution at 80 degrees C resulted in the death of almost all articular chondrocytes in the joint. This technique may be a satisfactory method for extensive cartilage ablation when performing arthrodesis by minimally invasive techniques.

Quality of life should be considered the primary outcome for measuring success of endometrial ablation

STUDY OBJECTIVE

To compare clinical and quality of life outcomes by validated instruments after endometrial ablation by four methods, and determine the primary outcome that most reflects procedure success.

DESIGN

Descriptive cohort study (Canadian Task Force classification II-2).

SETTING

Minimal-access gynecologic surgery unit in northeast England.

PATIENTS

One hundred thirty-nine women.

INTERVENTION

Endometrial ablation by one of four methods: Cavaterm, endometrial laser interstitial thermotherapy (ELITT), endometrial laser ablation (ELA), or NovaSure impedance-controlled system.

MEASUREMENTS AND MAIN RESULTS

Clinical outcomes were assessed according to menstrual outcome. Whereas amenorrhea rates were significantly different among the four techniques (chi2 = 9.42, p = 0.02), combined amenorrhea and hypomenorrhea rates were not significantly different (67%, 69%, 69%, 62%, chi2 = 0.38, NS) for Cavaterm, ELITT, ELA, and NovaSure, respectively. Quality of life, measured preoperatively by the EQ-5D index and EQ-5D vas, SF-12 physical and mental component scores, and sexual activity questionnaire pleasure, habit, and discomfort scores, were substantially improved 12 months after treatment. No significant differences were seen in quality of life scores between women after endometrial ablation and the general population.

CONCLUSION

Quality of life for women with menorrhagia is improved to a normal level by treatment with either first- or second-generation endometrial ablation.

The HydroThermAblator System for Management of Menorrhagia in Women with Submucous Myomas: 12- to 20-Month Follow-up

STUDY OBJECTIVE

To assess the safety and efficacy of the HydroThermAblator (HTA) system to treat patients with menorrhagia and submucous myomas up to 4 cm in diameter.

DESIGN

Retrospective, multicenter, cohort study (Canadian Task Force classification II-2).

SETTING

Two medical centers from a large, prepaid, multispecialty health maintenance organization.

PATIENTS

Twenty-two women.

INTERVENTION

HTA endometrial ablation.

MEASUREMENTS AND MAIN RESULTS

The HTA circulates free-flowing, heated (90 degrees C) saline in the uterine cavity for 10 minutes under direct hysteroscopic control. All procedures were performed in the office under local anesthesia after premedication with oral anxiolytic and analgesic agents. At least 1 year after treatment (average follow-up 15.4 mo, range 12-20 mo), women were contacted regarding their menstrual history. Success was defined as no additional medical or surgical intervention. Amenorrhea was defined as no bleeding, eumenorrhea as normal periods, and oligomenorrhea as less than a normal period. Twelve patients (54%) reported complete amenorrhea; 7 were premenopausal (41% amenorrhea rate) and 5 were postmenopausal (100% amenorrhea rate). Five (23%) reported oligomenorrhea and three (14%) eumenorrhea, and were very satisfied with the result. The overall success rate was 91%. Of two failures (9%), one woman had a repeat HTA 13 months later for menorrhagia. The other had a repeat HTA for persistent spotting and sustained a false passage and small perforation before the procedure began. She elected to have a vaginal hysterectomy 1 month later. Although the results are not statistically significant, patients were extremely satisfied with the outcomes, and no serious complications were related to the device or its use for this indication.

CONCLUSION

HTA is probably safe and effective in treating women with menorrhagia and submucous myomas up to 4 cm in diameter. It offers advantages over hysterectomy and electrosurgical resection since it is an office-based procedure, and significant advantages over other global ablation technologies that, by their design, are unable to treat significantly distorted uterine cavities.

A double-blind randomized trial comparing the Cavaterm and the NovaSure endometrial ablation systems for the treatment of dysfunctional uterine bleeding

OBJECTIVE

To compare two second-generation endometrial ablation systems in women with dysfunctional uterine bleeding (DUB) who want conservative surgical treatment.

DESIGN

A double-blind, randomized trial.

SETTING

A minimal access gynecological surgery unit in northeast England.

PATIENT(S)

Fifty-seven women diagnosed with DUB were recruited, with 55 undergoing surgery and completing 12-month follow-up.

INTERVENTION(S)

Thirty-seven women underwent a NovaSure endometrial ablation, and 18 had a Cavaterm endometrial ablation. Clinical and quality of life data were collected 6 and 12 months after treatment.

MAIN OUTCOME MEASURE(S)

Amenorrhea, menstrual change, quality of life, sexual activity, patient satisfaction, and procedure acceptability.

RESULT(S)

Amenorrhea, hypomenorrhea, eumenorrhea, and menorrhagia rates for the Cavaterm and Novasure groups at 12 months were 2/18 (11%) vs. 16/37 (43%); 11/18 (61%) vs. 10/37 (27%); 5/18 (27%) vs. 6/37 (16%); and 0/18 vs. 5/37 (13%), respectively. At 12 months, 83% and 92% of women were either satisfied or very satisfied in the Cavaterm or Novasure groups, respectively. There were no major complications in either group.

CONCLUSION(S)

Both the Cavaterm and the Novasure endometrial ablation systems are effective in reducing menstrual loss in women with DUB and achieve high rates of patient satisfaction. The Novasure system achieved a statistically significantly higher rate of amenorrhea in this study.

Assessment and comparison of intraoperative and postoperative pain associated with NovaSure and ThermaChoice endometrial ablation systems

STUDY OBJECTIVE

To assess and compare intraoperative and postoperative pain associated with NovaSure impedance-controlled endometrial ablation system and ThermaChoice system.

DESIGN

Prospective, international, multicenter, double-arm study (Canadian Task Force classification II-1). Setting. Academic medical centers and private offices.

PATIENTS

Sixty-seven premenopausal women with menorrhagia.

INTERVENTION

Endometrial ablation with either the NovaSure (37 women) or ThermaChoice (30) system. NovaSure-treated patients received no endometrial pretreatment; those treated with ThermaChoice received the recommended 3-minute suction dilatation and curettage.

MEASUREMENTS AND MAIN RESULTS

Standard pain measurement instruments (visual analog scale, numeric rating scale) were used to assess intraoperative and postoperative pain. Serum levels of prostaglandin-F(2alpha) were measured before and 5, 30, and 60 minutes after the procedure. Patients treated with the NovaSure system reported statistically significantly lower intraoperative and postoperative pain than those treated with the ThermaChoice system (p <0.0001). Procedure time was statistically significantly shorter with the NovaSure system (p <0.0001). Prostaglandin-F(2alpha) values did not differ statistically between groups.

CONCLUSION

The NovaSure system is associated with statistically significantly lower intraoperative and postoperative pain than ThermaChoice system, and endometrial ablation with NovaSure could become an office-based procedure.

Pregnancy after hydrothermal endometrial ablation and laparoscopic sterilisation

Hydrothermal ablation (HTA) is a newly introduced technique of endometrial ablation. This report describes the first case of pregnancy and miscarriage following successful HTA performed 4 years after laparoscopic tubal sterilisation. The diagnosis of such pregnancies can be difficult and the risk of pregnancy complications is potentially increased.

A multicenter evaluation of endometrial ablation by Hydro ThermAblator and rollerball for treatment of menorrhagia

STUDY OBJECTIVE

To compare results of endometrial ablation using the Hydro ThermAblator (HTA) and rollerball.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

Nine private practice and university centers in the United States.

PATIENTS

Two hundred seventy-six women with menorrhagia due to benign causes.

INTERVENTION

Endometrial ablation with the HTA (187 women) or rollerball (89).

MEASUREMENTS AND MAIN RESULTS

Menstrual diaries were kept for 2 weeks and 3, 6, and 12 months after treatment. Reduction in diary scores to 75 or lower at 12 months was considered a success. For patients treated and followed according to protocol, success rates were 77% for HTA and 82% for rollerball. Amenorrhea rates at 12 months were 40% and 51%, respectively.

CONCLUSION

Endometrial ablation with the HTA is safe and effective. It offers an advantage over rollerball ablation of being an office-based procedure, which reduces anesthesia requirements and obviates problems of fluid absorption.