Transcript Endometrial ablation

Endometrial ablation
Endometrial ablation broadly describes a
group of hysteroscopic procedures destroys
or resects the endometrial lining of the
uterus to sufficient depth prevents
regeneration of the endometrium and lead to
eumenorrhea.
For many women, ablation serves as a
minimum invasive and effective treatment of
abnormal uterine bleeding.
Indications:
Endometrial ablation is used to treat many cases of heavy
uterine bleeding which cannot be controlled with
medication.
Who should not have endometrial ablation?
Prior to ablation, complete evaluation of abnormal
uterine bleeding should be completed. Accordingly, it is
not recommended for women with certain medical
conditions, including the following :
• Genital tract malignancy.
• Woman wishing to preserve fertility.
• Pregnancy.
• Expectation of amenorrhea .
• acute pelvic infection.
• Prior uterine surgery e.g. classical C/S and
transmural myomectomy.
• Uterine size >12 weeks.
Techniques used for endometrial
ablation :
These are first or second generation depending
on their temporal introduction into use and the
need for hysteroscopic skill.
First
generation
tools require advanced
hysteroscopic skills and longer operating times
and can be associated with distension medium
complications, these tools include:
A-Neodymium : yttrium-aluminum –
gamet (Nd-YAG)Laser.
• It was the first ablative tool, introduced in the
1980s. Under direct hysteroscopic observation
and uterine distention with saline ,a Nd-YAG
laser fiber touches the endometrium and is
dragged across the endometrial surface.
• This creates furrows of photocoagulated tissue
that are 5 to 6 mm deep.
B- Transcervical Resection of the
endometrium (TCRE).
In attempt to lower cost from expensive laser
equipment, TCRE was developed. In addition
to less expensive, because of larger loop
diameter, TCRE can be completed more
quickly than laser fiber ablation & can thereby
reduce the risk of excess media absorption
due to long procedure duration.
In cases with concurrent intrauterine pathology
such as endometrial polyps or submucous
leiomyoma, TCRE, can excise these lesions in
addition to the endometrium.
However, TCRE has been associated with
higher rate of perforation, especially at the
cornual areas, where endometrium is thinner.
For this reason, many used a roller ball
electrosurgical electrode in combination with
TCRE, with roller ball used in the cornua
C-Roller ball.
• A 2-4 mm ball-shaped or barrel shaped
electrosurgical electrode can be rolled across
the endometrium as an effective means of
vaporizing the endometrium. Advantages of
roller ball ablation compared with TCRE
include: shorter operative time, less fluid
absorption and lower rate of perforation.
Unfortunately, it is not effective in the
treatment on intracavitary lesions, and
pathology specimens are not obtained.
To reduce risks and the specialized training
required for use of these early ablative tools,
second –generation nonresectoscopic methods
have been introduced during the past 10 years.
These tools use various modalities to ablate the
endometrium but do not require hysteroscopic
guidance. Modalities include :
1-Thermal balloon ablation
The first thermal balloon ablation system was
initially used in the early 1990s. Several thermal
balloon ablation systems are currently used
worldwide.
Only the ThermaChoice III Uterine Balloon
Therapy System is approved for use in the United
State. After cervical dilation to 5.5 mm, the
ThermaChoice device is inserted into the cavity,
a 5% dextrose and water solution is instilled into a
disposable, clear silicone balloon at the tip and
heated to coagulate the endometrium.
During the treatment, the fluid within the balloon is
circulated to maintain a temperature of 87°c (186° F) for 8
minutes. The balloon can be introduced without
hysteroscopic assistance into the uterine cavity and when
inflated, conforms to the cavity contour.
All hot-liquid balloon devices require no advance
hysteroscopic skills, and complication rate are low.
Disadvantages include the requirement of an anatomically
normal uterine cavity and of pharmacologic thinning
prior to thermal ablation. Alternatively , mechanical
thinning can be accomplished with dilatation and curettage
prior to ablation.
2- Cryoablation
Endometrial ablation can be achieved with extreme cold.
This system was approved for use in the United State
in 2001. Similar to the physics of cervical cryotherapy,
gases compressed under pressure with this unit can
generate temperatures of -100° to -120° C at the
cyroprobe tip to produce an ice ball. As an ice ball
grows, its leading edge advances through tissue, and
cryonecrosis develops in those tissues reaching
temperature less than -20°C. After cervical dilatation,
the cyroprobe s 1.4 inch cryotip is placed against one
side of the endometrial cavity and advanced to one
uterine cornua.
Concurrent transabdominal sonography is required to ensure
accurate cryotip placement and surveillance of the increasing
ice ball diameter, which is seen as an Enlarging hypoechoic
area. The first freeze is terminated after 4 minutes or sooner, if
the advancing iceball reaches to within 5 mm of the uterine
serosa. The cryotip is allowed to warm, is removed from the
cornua, and is redirected into the contralateral cornua.
3-Microwave Ablation
• The microwave endometrial ablation (MEA) technique uses
microwave energy to destroy the endometrium. During the
procedure, a microwave probe is inserted until the tip reaches
the uterine fundus. Once inserted, the probe tip is maintained
at 75°c to 80°c and moved slowly from side to side. Microwave
energy is spread with a minimum penetration of 6mm over the
entire surface of the uterine cavity.
• Speed is an advantage, with the entire treatment completed in 2
to 3 minutes. Due to complications of bowel burns in patients
without evidence of uterine perforation, to obtain FDA
approval, the manufacturers of the MEA system recommend
preoperative assessment of myometrium thickness at least a
10 mm thickness throughout the uterus.
4- Impedance-controlled
Electocoagulation
• The NovaSure endometrial ablation was approved
for marketing in the United State in 2001. The
system consist of high-frequency (radiofrequency)
bipolar electrosurgical generator and a single-use,
metal, fan-shaped device constructed of fabric –like
mesh.
• The mesh fan is designed to contour to the shape of
the endometrial cavity. The treatment time of 2
minutes results in desiccation of endometrium. An
advantage of this system is that it does not require
preoperative endometrial preparation and it has
been used successfully in patients with small
submucosal lieomyomas and poylyps.
5-hysteroscopic thermal ablation
The Hydro ThermAblator (HTA) system allows
treatment of the endometrium concurrent
with submucous lieomyomas, polyps, or
abnormal
uterine
anatomy.
Another
advantage is that it is performed under direct
hysteroscopic visualization, allowing the
surgeon to observe the endometrium being
destroyed.
This tool is designed to ablate the endometrial lining of the
uterus by heating an uncontained saline solution to a
temperature of 90°C and circulating it through the uterus for
10 minutes. Spill through the fallopian tubes is avoided
because hydrostatic pressure during the procedure remains
below 55mm Hg, which is well below pressures needed to
open the fallopian tubes to peritoneal cavity. Similarly, the
water seal created between the hysteroscope and internal
cervical os prevents leakage of fluid into the vagina. For this
reason, care should be taken nor to dilate the cervix to a
diameter more than 8mm.
Can I get pregnant after having
endometrial ablation?
Pregnancy is not likely after ablation, but it
can happen. If it dose, the risk of miscarriage
prematurity, abnormal placentation &
perinatal morbidity are increase. If a woman
still wants to become pregnant, she should
not have this procedure. Some women
choose a sterilization procedure at the time
of endometrial ablation to prevent
pregnancy.
What should I expect after the procedure?
After endometrial ablation, you may experience:
• Cramps. You may have menstrual- like cramps for a few days.
Over the counter medications such as ibuprofen or
acetaminophen can help relieve cramping after the procedure.
• Vaginal discharge. A watery discharge, mixed with
blood, may occur for a few weeks. The discharge is typically
heaviest for the first few days after the procedure.
• Frequent urination. You may need to pass urine more
often during the first 24 hours after endometrial ablation.
• You may need to avoid intercourse and tampon use
for a period of time after the procedure. It may take a few
months to see the results, but endometrial ablation usually
succeeds in reducing the amount of blood lost during
menstruation.
The success rates
As a general role, of all women undergoning
endometrial ablation with second generation
technique
• 40% will become amenorrhoeic
• 40% will have markedly reduced menstrual
loss
• 20% will have no difference in their bleeding.
The risks associated with endometrial
ablation :
 A puncture injury (perforation) of the
uterine wall from surgical instruments.
Heat or cold damage to nearby organs.
Pain, bleeding or infection.
Fluid over load due to absorption of
distension medium (resection only).
Postoperative
 Advantage to endometrial ablation include rapid
patient recovery and low incidence of
complications. Patients may resume normal diet
and activities as tolerated.
Patients may expect light bleeding or spotting
during the first postoperative days as necrotic
endometrial tissue is shed. A serosanguinous
discharge follows for 1 week and is replaced by a
profuse and watery discharge for another 1 to 2
weeks.
Thank you•