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    The MIGS approach to fixing failed endometrial ablation

     

    Approach to the well-developed uterine cavity

    Well-developed cavities are often associated with early EA failures—within 6 months of the procedure. These cavities are generally devoid of the dense intrauterine synechiae and often contain submucous leiomyomas, large uterine septa, or substantially enlarged uterine cavities (sagittal dimensions ≥11 cm or transverse dimensions ≥8 cm). Septa, when present, generally require at least partial removal in order to facilitate adequate treatment of the uterine cornua and tubal ostia. When present, submucous leiomyomas must be resected in order to gain full access to the uterine cavity. After these initial measures, a standard endomyometrial resection is performed.14 The goal of UGRH is removal of at least 4 mm of tissue beneath the basal layer of the endometrium, a depth that is reduced to 2 mm–3 mm at the cornual regions. At the close of the procedure, deep coagulation of the myometrium is accomplished with a 2-mm or 3-mm ball-end electrode at 120 watts of coagulation current.

    Ultrasound guidance—dynamic scanning

    U/S guidance is provided by performing dynamic scanning—a combination of sagittal and transverse scanning to ascertain that the resectoscope is, at least initially, advanced in the midline of the uterus. This is critically important in the absence of traditional intrauterine landmarks. This technique is used to bring the loop to desired areas of interest and is especially important in RHS of the tubular cavity. Sagittal scanning is most appropriate when resecting continuous strips of tissue in the long axis. It is often used preferentially to define the minimal distance between the operative site and the serosa of the anterior, posterior, and lateral walls. Transverse scanning is often used as a “cross-check” when operating on the lateral walls and in the cornual regions. Coordination between sonographer and surgeon is imperative in order to maintain optimal safety and guidance to areas that are sequestered by intrauterine scarring.

    Results

    UGRH was first reported by this author in 2001.11 In a series of 26 women—predominantly failures of hysteroscopic EA or resection techniques—hysterectomy was avoided in 88.5% during a mean follow-up of 23.2 +22.7 months. There were no complications associated with the procedure.

    In a more recent series of 50 women presenting with delayed complications following a variety of NREA or “global” techniques, UGRH was completed without any intraoperative or perioperative complications.12 Eighty percent of subjects experienced no further cyclic pelvic pain and were amenorrheic, oligomenorrheic, or experienced occasional scant flow. Two women (4%) reported amenorrhea with mild cyclic pain and another 2 (4%) reported amenorrhea with moderate cyclic pain. In all, 89.8% of subjects were very satisfied with their outcomes and were able to avoid further surgery during this limited follow-up period.

     

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