Endometrial ablation by hysteroscopic instillation of hot saline solution

[Analysis from the French DRG-based information system (PMSI) of conservative surgical treatment for abnormal uterine bleeding in 2008-2010]

OBJECTIVE

To evaluate the conservative surgical treatment for abnormal uterine bleeding from the Medicalized Information System Program (PMSI).

MATERIALS AND METHODS

The diagnosis codes were selected from 10th version of the international classification disease. A transversal and longitudinal descriptive analysis was performed from hospital stays, patient's characteristics, medical procedures between 2008-2010.

RESULTS

Nineteen thousand six hundred and seventy-nine patients were admitted in hospital (public or private) for treatment of abnormal uterine bleeding. Endometrial ablation increased by 16,7%, 10.2% for first generation technique (G1) and 63.5% for second generation techniques (G2). G2 were used in 15% of indications. The median age was respectively 45.2±6.4 years old versus 45.8±4.9 years old for G2. The median length of hospital stay was 1.6 ±1with 69% of patients in ambulatory care. The likelihood to have a hysterectomy in the 3 years follow-up was higher after G1 than G2 treatments (P=0.0034) for the patients above 40 years old. In longitudinal study, defined only by endometrial hyperplasia, 11,532 patients were included and only 8.2% had been treated by G2.

CONCLUSION

In spite of the international guidelines since 2008, 85% of patients treated with first generation surgical technique. The failure rate defined by a re-ablation or a hysterectomy is higher after G1. This result must be discussed in relationship with cost effective aspects.

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.

Hysteroscopic surgery

Hysteroscopy and visually directed endometrial sampling have replaced blind curettage for the diagnosis of endometrial disease. Hysteroscopy can be used to detect endometrial cancer and various premalignant lesions, as well as to diagnose intrauterine polyps and submucous fibroids. It can also be used to locate lost intrauterine devices, assess the shape and size of the endometrial cavity during an infertility work-up and to visualise intrauterine septae and adhesions. If the hysteroscopist possesses special skills and training, it can be used to perform intrauterine sterilisation by occluding the tubal ostia. The ability to perform endometrial ablation as an alternative to hysterectomy in patients with menorrhagia has led to reduction in the number of hysterectomies performed. Long-term follow-up has confirmed the success of this procedure, but it is not without complications. The inherent dangers and complications of endometrial ablation and the considerable skill and training it requires has led to the development of numerous second-generation devices, which can involve balloons that are heated with circulating fluid, impedance-controlled endometrial ablation or surface electrodes, heated fluid running through the hysteroscope under direct vision or the use of microwaves or cryotherapy. This chapter reviews the techniques, potential complications and evidence for the effectiveness of the common diagnostic and therapeutic hysteroscopic procedures.

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.

Hysteroscopic and nonhysteroscopic endometrial ablation

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.

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

OBJECTIVE

To compare two methods of endometrial ablation, hysteroscopic rollerball electrocoagulation (RBE) and non-hysteroscopic uterine balloon thermal ablation (Thermachoice trade mark ), regarding efficacy for reducing dysfunctional uterine bleeding and patients satisfaction rate.

METHODS

A randomised controlled study was performed in a teaching hospital at the department of gynaecology. One hundred and thirty-seven premenopausal women with dysfunctional uterine bleeding proved by validated menstrual score list were included. Endometrial ablation by a hysteroscopic or non-hysteroscopic method was performed by one gynaecologist.

RESULTS

Reduction of menstrual blood loss was significantly more successful at 24 months for thermal ablation with uterine balloon. Success rate measured by menstrual score < 185 for rollerball and thermal balloon ablation are equivalent at 12 and 24 months post-operatively. Satisfaction of the patients for both methods at 24 months post-operatively is not significantly different (respective 75% for rollerball and 80% for uterine balloon).

CONCLUSIONS

Endometrial ablation by uterine balloon thermal ablation (Thermachoice trade mark ) is equally effective as hysteroscopic RBE of the endometrium.

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.

Evaluation of HydroThermAblator and Rollerball Endometrial Ablation for Menorrhagia 3 Years after Treatment

STUDY OBJECTIVE

To compare the safety and efficacy of endometrial ablation using HydroThermAblator (HTA) and rollerball (RB) for treatment of menorrhagia.

DESIGN

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

SETTING

Nine private practice and university centers in the United States.

PATIENTS

Two hundred seventy-six women.

INTERVENTION

Hysteroscopic endometrial ablation with the HTA (187 women) and RB (89).

MEASUREMENTS AND MAIN RESULTS

Bleeding was assessed by pictorial diaries for 12 months, with patient interviews at 24 and 36 month. Amenorrhea rates, reduction of bleeding to normal levels or less, and patient satisfaction were tracked for 36 months, with rates in the HTA group of 53%, 94%, and 98% and in the RB group of 46%, 91%, and 97%, respectively.

CONCLUSION

Endometrial ablation with the HTA is a safe, effective, and durable treatment of menorrhagia in a broad patient population. It offers advantages over RB by reducing anesthesia requirements, reducing operating time, and eliminating risks of excessive fluid absorption, and is more easily learned.

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.

Endometrial ablation as an alternative to hysterectomy

In the United States, as many as two million women (ie, 22%) each year will consult a physician about menorrhagia (ie, excessive menstrual bleeding). Seven hundred thousand hysterectomies are performed in the United States each year for symptomatic menorrhagia. The procedure cost, risk, and complications, combined with the fact that a large number of posthysterectomy specimens show no abnormality, suggest that the majority of hysterectomies performed for menorrhagia are unnecessary. These data suggest that a less invasive procedure that destroys the endometrial lining but preserves the uterus would be a beneficial procedure for patients with excessive uterine bleeding. Treatment for menorrhagia may include hormone therapy, endometrial curettage, endometrial ablation, and hysterectomy. Women who are opposed to hysterectomy and those for whom other treatment options were unsuccessful can consider ablation rather than hysterectomy.

Advances in endometrial ablation

The evolution of the surgical treatment of dysfunctional uterine bleeding has resulted in the design and manufacture of instrumentation that is minimally invasive, has a low risk profile, and is technically simple to operate. Whereas hysterectomy was the only definitive surgical option before 1981, operative hysteroscopy with transcervical resection of the endometrium and rollerball ablation of the endometrium gained favor in the mid-1980s and 1990s. During the past 10 years, devices dedicated entirely to the ablation (or destruction) of the endometrium have been designed, modeled, tested, and approved for clinical use in the United States. This review describes the methods by which the technologies are evaluated and approved for clinical use by the Food and Drug Administration. In addition, the reported efficacy of each approved device is reviewed. The complications associated with the devices, as well as the potential long-term risks of endometrial ablation, also are reported. Finally, the cost for device disposables and nondisposables is presented.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to list the various FDA-approved uterine ablation devices, compare the effectiveness of the various uterine ablation devices, and summarize the various adverse events associated with the use of the uterine ablation devices.

Endometrial ablation using hysteroscopic instillation of hot saline solution into the uterus

OBJECTIVE

To evaluate the clinical effectiveness and safety of endometrial ablation by hysteroscopic instillation of hot saline using the Hydro-Therm-Ablator (HTA) system.

METHODS

A total of 14 patients with menorrhagia, underwent the HTA procedure under general anethesia. Follow up of 9-18 months is reported. Three patients had undergone tubal ligation years before the procedure and one underwent it immediately after HTA at the same session.

RESULTS

One procedure was cancelled due to technical problems, and roller-ball ablation was performed. There were no procedure related complications. A total of 11 patients reported significant reduction in bleeding, or amenorrhea, 9-18 months after the HTA procedure. One patient, although eumenorrheic after the ablation, considered the procedure a failure and requested hysterectomy. One patient with menorrhagia 3 months after the procedure, had a second HTA ablation and is now amenorrheic.

CONCLUSIONS

This series of patients who underwent HTA ablation had successful reduction of menorrhagia to oligomenorrhea or amenorrhea.

Hysteroscopic endomyometrial resection of three uterine sarcomas

STUDY OBJECTIVE

To describe our experience with three uterine sarcomas associated with hysteroscopic endometrial ablation.

DESIGN

Cohort study (Canadian Task Force classification II-2).

SETTING

University-affiliated teaching hospitals.

PATIENTS

Three of 2402 women undergoing hysteroscopic endometrial ablation who had uterine sarcomas.

INTERVENTION

Hysteroscopic endomyometrial resection.

MEASUREMENTS AND MAIN RESULTS

One low-grade endometrial stromal sarcoma and two carcinosarcomas were resected. After hysterectomy in two patients, no residual cancer was identified in one of them. The third patient was an 82-year-old woman with moderate menorrhagia who refused hysterectomy. After endomyometrial resection she remained amenorrheic for the last 14 months of her life.

CONCLUSION

From our experience the incidence of uterine sarcomas is approximately 1/800 women undergoing hysteroscopic ablation for abnormal uterine bleeding. Complete endomyometrial resection is feasible and may be offered as diagnostic and palliative therapy in women at high risk for hysterectomy.

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.

GLOBAL ENDOMETRIAL ABLATION

Hysteroscopic endometrial ablation was introduced in the 1980's as an alternative to hysterectomy in women who failed medical management. Global endometrial ablation was introduced in the 1990's as an easier, safe, and equally effective alternative to hysteroscopic ablation. Several devices have been introduced, some of which are still undergoing feasibility studies or clinical trials. These devices include: three hot water intrauterine balloons, two intrauterine free saline solutions, a multielectrode electrocoagulating balloon, a 3-D bipolar electrocoagulation probe, a microwave, a diode fibre laser, and at least three cryoprobes. These devices require less operator skill and no irrigant or distending solutions. All require either heat or cold to destroy the endometrium. Although all devices are promising and have produced impressive preliminary results, the long-term efficacy, complication rates, and cost effectiveness have not been established. This review describes all devices as they appeared chronologically and presents only peer-reviewed data.

Global endometrial ablation technologies

The value of extirpative surgery for excessive uterine bleeding is questionable. A number of technologies have been developed that destroy the endometrial lining while preserving the uterus. This article compares and contrasts multiple modalities of global endometrial ablation technology.

A simple method of coagulating endometrium in patients with therapy-resistant, recurring hypermenorrhea

STUDY OBJECTIVE

To assess the efficacy, safety, and tolerability of hydrothermablation in the treatment of recurrent menorrhagia.

DESIGN

Prospective, nonrandomized survey (Canadian Task Force classification II-2).

SETTING

Endoscopic center at a university hospital.

PATIENTS

Eighteen premenopausal women with recurring menorrhagia resistant to hormone treatment.

INTERVENTIONS

Coagulation of the endometrium at 90 degrees C for 10 minutes under hysteroscopic control.

MEASUREMENTS AND MAIN RESULTS

During follow-up of least 12 months, nine (50%) of patients had amenorrhea and 17 (94%) had reduction or cessation of pathologic blood flow. One woman underwent hysterectomy because of recurrent dysmenorrhea.

CONCLUSION

In this study, hydrothermablation was a safe and effective method of treating recurrent menorrhagia. It does not require extensive training and may help avoid hysterectomy. (J Am Assoc Gynecol Laparosc 6(3):265-268, 1999)

Endometrial laser intrauterine thermo-therapy (ELITT): a revolutionary new approach to the elimination of menorrhagia

Various non-hysteroscopic procedures have been developed in the attempt to treat dysfunctional uterine bleeding that fails to respond to medical treatment efficiently and easily. Among these procedures is low-dose laser radiation of the endometrium with the diode source, which is characterized by the highest incidence of amenorrhea.

Histologic studies of the effects of circulating hot saline on the uterus before hysterectomy

STUDY OBJECTIVE

To evaluate a new device for endometrial ablation.

DESIGN

(Canadian Task Force classification II-1).

SETTING

University-affiliated hospital.

PATIENTS

Thirty-two women scheduled for hysterectomy.

INTERVENTIONS

Endometrial ablation and hysterectomy.

MEASUREMENTS AND MAIN RESULTS

The new device for endometrial ablation was evaluated by studying depth of necrosis after staining for the oxidative enzyme NADH. Uniform endomyometrial necrosis was achieved at a depth of 2 to 4 mm with 90 degrees C saline circulated for 10 minutes.

CONCLUSION

The procedure was successful in all patients, and there were no adverse clinical sequelae. (J Am Assoc Gynecol Laparosc 6(3):269-273, 1999)

Modern treatments of menorrhagia attributable to dysfunctional uterine bleeding

Menorrhagia (excessive uterine bleeding) affects some 20 percent of the women of reproductive age worldwide. The following review describes known and theorized etiologies of the disorder, followed by a discussion of treatment options that are currently in use as well as those on the horizon. There is much interest internationally in decreasing hysterectomy rates, particularly for those women with abnormal bleeding and anatomically normal uteri. It is these women who are the focus of this paper. Pharmacotherapy and surgery are the mainstay treatments for such patients with menorrhagia secondary to dysfunctional uterine bleeding. Most commonly, hormonal and nonhormonal medications are followed by dilatation and curettage, and ultimately, in many cases, hysterectomy. Endometrial ablation techniques have been evolving since the 1980s in response to the need for an efficacious, safer, and more cost-effective alternatives to hysterectomy. Hysteroscopic ablation achieves these goals but is difficult technically and requires significant additional training even for otherwise skilled and experienced gynecologists. The current decade has seen the development of many innovative approaches to performing endometrial ablation. These methods are intended to be much simpler to perform with less risk than electrosurgical or laser endometrial ablation. The final section of this article presents the published data to date on these new technologies, which should (in their refined state) revolutionize the treatment of menorrhagia secondary to dysfunctional uterine bleeding.