The MIGS approach to fixing failed endometrial ablation
Dr. Wortman is Director, Center for Menstrual Disorders, Rochester, New York, and Clinical Associate Professor of Gynecology, University of Rochester Medical Center.
The introduction of resectoscopic endometrial ablation (REA) in 1981 ushered in an important era in minimally invasive management of abnormal uterine bleeding (AUB) unresponsive to medical management.1 Although REA gained only limited acceptance in the gynecologic community, the introduction of non-resectoscopic endometrial ablation (NREA) techniques was widely embraced. In 2008 alone, some 312,000 NREA procedures were performed in the United States.2
Despite quite encouraging initial results with endometrial ablation (EA), a 2007 ACOG Practice Bulletin noted that 24% incidence of hysterectomy within 4 years after EA.3 One 8-year follow-up of 3681 women noted that delayed complications continued to increase throughout the surveillance period.4
The delayed complications of EA manifest themselves in 1 of 3 ways: persistent or recurrent vaginal bleeding, cyclic pelvic pain, and inability to adequately assess the endometrium in women who later require sampling.5
Persistent or recurrent vaginal bleeding—occurring months or years following EA—has been attributed to inadequate endometrial destruction,6 unsuspected deep adenomyosis,7 or the occurrence of new pathology—myomata, polyps, endometrial hyperplasia, or cancer. Pelvic pain is generally cyclic and has been attributed to cornual and central hematometra as well as to postablation tubal sterilization syndrome (PATSS).5 McCausland et al noted that the etiology of cyclic pelvic pain “following both resectoscopic and nonresectoscopic endometrial ablations is due to the intrauterine scarring and contracture that can occur following the procedure.”5 Inability to adequately assess the uterine cavity is an under-reported delayed complication following EA. Ahonkallio et al demonstrated that endometrial biopsies failed in 23% of women with previous EA and were likely unreliable in many of the remaining patients because endometrium is often trapped in the sequestered cornual regions.8 Any of these delayed complications is a sufficient reason to perform a hysterectomy.
Several authors have reported “repeat” or “reoperative” EA procedures. Gimpelson was able to successfully treat 16 women who underwent reoperative hysteroscopic surgery (RHS) with either Nd:YAG laser or electrosurgical techniques—avoiding hysterectomy in all subjects during the surveillance period.9 The largest series of RHS was reported by Istre et al, who offered RHS to 118 women and were able to avoid hysterectomy in 72% of subjects during a mean follow-up period of 22 months.10 In 2001, the author reported performing ultrasound (U/S)-guided RHS on 26 women—mostly REA failures—88.5% of whom avoided hysterectomy during a mean follow up period of 23.2+22.7 months.11 More recently the author reported the results of U/S-guided reoperative hysteroscopy (UGRH) for managing NREA failures in 50 women, 88.9% of whom avoided hysterectomy during a mean follow-up period of 18.1 months.12
My experience suggests that combined use of U/S guidance and hysteroscopic resection techniques provide 2 distinct advantages over other methods of RHS. First, U/S enables access to areas of the uterus that are sequestered by dense synechiae, enabling one to locate areas of hematometra, endometrial regrowth, and leiomyomas in a setting with few intrauterine landmarks. Second, hysteroscopic resection provides ample tissue for histologic analysis—especially crucial in the evaluation of women with postmenopausal bleeding.
Here I will summarize patient selection, operating room set-up, and technique for, and results associated with UGRH.