Transcript Endometrial Ablation

IN THE NAME OF GOD
Endometrial Ablation
Dr Safoura Rouholamin
AUB
AUB affects up to 50 percent of
premenopausal women
 Heavy menstrual bleeding is a common
problem.
 one in 20 women of reproductive age
consults her practitioner
 In the past, by the age of 55 one in five
women had had a hysterectomy
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Hysterectomy is second only to cesarean
section among surgical interventions in
women of fertile age
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In fact, 90% of hystrectomies are
performed in cases of abnormal uterine
bleeding
Treatments for heavy menstrual bleeding
 Medical:
◦ tranexamic acid
◦ mefenamic acid
◦ combined OCP
◦ progestin agent
◦ GnRh agonists
◦ Mirena (The levonorgestrel IUD)
Treatments for heavy menstrual bleeding
 Surgical:
◦ Endometrial Ablation
◦ hysterectomy
Endometrial Ablation
Resectoscopic techniques
 Non-Resectoscopic techniques
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Resectoscopic techniques
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Resectoscopic techniques are performed
under hysteroscopic visualization, using
resectoscopic instruments to ablate or
resect the endometrium
In current practice, non-resectoscopic
endometrial ablation is performed in most
cases.
resectoscopic ablation: shape or size of the
uterine cavity will not accommodate a nonresectoscopic device or if the patient has
had multiple cesarean deliveries, to avoid
ablating over the hysterotomy scar
There are currently four techniques
 (1) endometrial dessication with an
electrosurgical rollerball or rollerbarrel
(2) resection with a monopolar or bipolar
loop electrode
 (3) radiofrequency vaporization
 (4) laser vaporization
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Hysteroscopy: Resectoscopic
instruments
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All methods dessicate the endometrium to the level
of the basalis.
The rollerball and rollerbarrel use thermal energy for
heating the tissue to a temperature between 60 to
90ºC, which dessicates and destroys the tissue.
No tissue is removed.
Thermal energy is also used with the monopolar and
bipolar loop electrodes.
loop electrodes also resect the endometrium beyond
the basalis layer to the myometrium.
The resected tissue is sent to pathology for histologic
diagnosis.
.
The vaporizing electrodes and laser fibers use
high energy to rapidly heat the intracellular water
to 100ºC, causing vaporization of tissue. No
tissue is removed.
 Rollerball endometrial ablation is the most
commonly used resectoscopic ablation method.
Wire loop endomyometrial resection requires
advanced hysteroscopic skills because of the risk
of perforation, bleeding, and fluid absorption.
 Laser and vaporizing electrode ablation are not
commonly performed due to expense of the
equipment these methods require
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start the desiccation at the cornua and then
move to the anterior fundal wall due to
bubble formation in the uterine cavity.
Complete the ablation on the posterior
wall since the bubbles formed will be
anterior.
Activate the current and bring the rollerball
towards the surgeon.
Avoid dessication of the cervico-uterine
junction since this may result in cervical
stenosis or uterine occlusion.
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Most women with successful endometrial
ablation will have a reduction in uterine
blood flow, but not amenorrhea
PATIENT SELECTION
The primary indication :treatment of
ovulatory menorrhagia in
premenopausal women
 Ablation is usually used to treat women
with chronic menorrhagia.
 It may also be used for acute abnormal
uterine bleeding in hemodynamically
stable women in whom medical therapy
is contraindicated or unsuccessful
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Endometrial ablation is not indicated for
women who wish to be amenorrheic for
nonmedical reasons
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The endometrium must be destroyed or
resected to the level of the basalis, which
is approximately 4 to 6 mm deep,
depending upon the stage of the
menstrual cycle
 endometrial
sampling should be
performed in all women prior to
undergoing endometrial ablation
Contraindications
Contraindications :
 ●Pregnancy
 ●Known or suspected endometrial
hyperplasia or cancer
 ●Desire to preserve fertility
 ●Active pelvic infection
 ●Intrauterine device (IUD) in place
 ●Previous transmyometrial uterine
surgery
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relatively contraindication
postmenopausal
 congenital uterine anomalies (bicornuate
uterus)
 uterine cavity length that is greater than
10 to 12 cm
 severe myometrial thinning
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Endometrial ablation in women with
thinning of the myometrium may result in
injury to the adjacent viscera (bladder,
bowel) if the energy used for ablation
passes through the uterine tissue
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Zarek S, Sharp HTGlobal. endometrial ablation devices. Clin Obstet Gynecol. 2008;51(1):167.
There are no data to establish the
minimum myometrial thickness required
to prevent such complications.
 There is no evidence that prior cesarean
delivery increases the risk of
complications associated with
endometrial ablation
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Gangadharan A, Revel A, Shushan AEndometrial thermal balloon ablation in women with previous
cesarean delivery: pilot study. J Minim Invasive Gynecol. 2010 May;17(3):358-60.
Risk factors for endometrial
cancer
Many of the reports of endometrial cancer
after endometrial ablation have been in
women with chronic
anovulation and/or endometrial hyperplasia
 Women with these conditions are also often
obese or have diabetes and/or hypertension
and thus may have contraindications to some
medical therapies (eg, steroid hormones,
antifibrinolytics) and be at increased risk of
complications if they undergo major surgery.
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We suggest that progestin supplementation
be offered to prevent hyperplasia until
ovulation is reestablished or menopause
occurs in the presence of chronic
anovulatory states.
Correction of anovulation is the optimal
approach to treatment for these women.
In women in whom this is not possible,
other treatment options (eg, progestins) may
be preferable to endometrial ablation.
tamoxifen
We suggest not performing endometrial
ablation in women who are taking
tamoxifen.
 Such women are at an increased risk of
endometrial cancer, and ablation may
interfere with the later diagnosis of this
disorder.
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Capuano I, Caporale A, Vagnetti P, Di Domenico A, Felicetti M, Torella M, Borrelli AL.[Endometrial
ablation versus hysterectomy in women treated with tamoxifen]. Minerva Ginecol. 2007;59(5):499.
Lynch syndrome (hereditary nonpolyposis
colorectal cancer) are at a markedly
increased risk of endometrial cancer and
are advised to undergo hysterectomy
after they have completed childbearing.
 Abnormal uterine bleeding in this
population should not be treated with
endometrial ablation.
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Leiomyomas or polyps
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Endometrial ablation in women with
intracavitary (submucosal or intramural
myomas that protrude into the uterine
cavity) fibroids is controversial.
Comparative data show that nonresectoscopic devices are less effective in
women with intracavitary fibroids than in
those with a normal uterine cavity
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Glasser MH, Zimmerman JD.The HydroThermAblator system for management of menorrhagia in
women with submucous myomas: 12- to 20-month follow-up. J Am Assoc Gynecol Laparosc.
2003;10(4):521.
Adenomyosis
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Adenomyosis (uterine adenomyomatosis)
is not a contraindication to endometrial
ablation, although women with this
condition may have a lower treatment
success rate.
El-Nashar SA, Hopkins MR, Creedon DJ, St Sauver JL, Weaver AL, McGree ME, Cliby WA, Famuyide
AO.Prediction of treatment outcomes after global endometrial ablationObstet Gynecol. 2009;113(1):97.
Parity
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Nulliparity is not a contraindication to
endometrial ablation. Grand multiparity
appears to be a risk factor for treatment
failure.
In the retrospective study of 816 women
described in the preceding paragraph,
women with a parity of ≥5 compared to <5
had a six-fold increased risk of subsequent
repeat endometrial ablation or
hysterectomy
El-Nashar SA, Hopkins MR, Creedon DJ, St Sauver JL, Weaver AL, McGree ME, Cliby WA, Famuyide
AO.Prediction of treatment outcomes after global endometrial ablationObstet Gynecol. 2009;113(1):97.
Bleeding disorders or
anticoagulation
Coagulopathy due to bleeding disorders
or anticoagulant medications is a potential
etiology of heavy menstrual bleeding.
 Most methods of endometrial ablation
are appropriate for use in such women.
 Endometrial resection should be avoided
in women who have a bleeding disorder
or are taking anticoagulants.
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CURRENT NON-RESECTOSCOPIC
ABLATION DEVICES
●bipolar radiofrequency (Novasure)
 ●hot liquid filled balloon (ThermaChoice)
 ●cryotherapy (Her Option)
 ●circulating hot water (Hydro ThermAblator)
 ●microwave (Microwave Endometrial Ablation).
 Two other brands of hot liquid filled balloon
devices are available outside of the United States:
Cavaterm and Thermablate EAS
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Endometrial Ablation
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Postoperative pain was similar after either methods
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Second generation techniques have lower rate of:
◦ Uterine perforation
◦ Excessive bleeding
◦ Fluid overload
◦ Cervical laceration
Endometrial ablation
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We found that second generation techniques
were at least as effective as first generation
techniques more over they are:
◦ Simpler
◦ Quicker
◦ Require less skill on the part of operator
◦ Can be attempted under local anaesthetic
◦ Fewer operative complication
GENERAL OPERATIVE
TECHNIQUE
Positioning, sterile preparation, and
cervical dilation are the same as for
hysteroscopy
 Most non-resectoscopic techniques do
not require hysteroscopy, with the
exception of the Hydro ThermAblator,
during which hot water is instilled into
the uterus through a hysteroscopic sheath
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For other techniques, preoperative hysteroscopy
is necessary only if the uterine cavity has not
been assessed for leiomyomas or endometrial
polyps in the preoperative period
 the manufacturer of the microwave ablation
system advises hysteroscopic evaluation before
and after ablation
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Endometrial preparation
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The goal of endometrial preparation is to
thin the endometrium to facilitate tissue
destruction.
Hormonal suppression with a gonadotropinreleasing hormone (GnRH) agonist (eg,
intramuscular leuprolide 3.75 mg/month) is
the most commonly used method of
endometrial preparation prior to
endometrial ablation.
Hormonal pretreatment should be initiated
30 to 60 days prior to the procedure
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progestins (eg, oral medroxyprogesterone
acetate [MPA] 15 mg daily) instead of GnRH
agonists offers the advantage of fewer
adverse effects (eg, menopausal symptoms).
Randomized trials comparing progestins
or danazol to GnRH agonists have found no
difference in postablation improvement in
uterine bleeding; however, these trials lacked
statistical power [53,54].
We prefer not to use danazol, since it is
poorly tolerated by most women.
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Nonhormonal methods of preparation
include: performing the procedure during
the follicular phase of the menstrual cycle
and uterine curettage
Bhatia K, Doonan Y, Giannakou A, Bentick B.A randomised controlled trial comparing GnRH antagonist
cetrorelix with GnRH agonist leuprorelin for endometrial thinning prior to transcervical resection of
endometrium. BJOG. 2008;115(10):1214.
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The endometrial cavity should be assessed
preoperatively in all patients undergoing endometrial
ablation.
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Performing this assessment of the uterus during the
preoperative evaluation is optimal, since it helps to
guide surgical planning
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If the uterine cavity has not been assessed
preoperatively, a diagnostic hysteroscopy should be
performed just prior to the ablation procedure
Postoperative hysteroscopy is potentially useful
to identify areas of remaining endometrium or
detect uterine perforation.
 Some surgeons ablate endometrial remnants
using resectoscopic instruments
 clinical benefit ??
 There are no data regarding whether small
amounts of residual endometrium following nonresectoscopic ablation impact treatment success
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ABLATION METHODS
Bipolar radiofrequency (Novasure) :The
NovaSure generator applies up to 180 watts of
power.
 The average treatment time is just over one
minute and the average depth of ablation is 4 to
5 millimeters
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Uterine requirements — Uterine cavity and
cervical dilation parameters for Novasure
ablation are :
●Diameter of device 7.5 mm
●Sounded cavity length ≥6 to ≤10 cm;
alternatively, ≥4 cm from internal cervical os to
fundus
●Cornua to cornua distance ≥2.5 cm
●Women with submucosal leiomyomas or with
endometrial polyps >2 cm were excluded from
the FDA approval studies
●No irregularly shaped cavities
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Outcome — five or more years
reduced uterine bleeding (97 to 98 percent)
amenorrhea (75 to 97 percent)
low rates of repeat ablation (1 to 4 percent)
hysterectomy (3 to 8 percent)
Novasure ablation does not require
endometrial preparation
Microwave Endometrial Ablation
(MEA)
9.2 GHz, 30 watt, microwave system
 this energy will produce a tissue
temperature of 75 to 85ºC at a depth of 6
mm.
 the surgeon moves the probe from cornu to
cornu and across the lower uterine segment
until the entire endometrium has reached
the desired temperature.
 Total treatment time is three to five minutes
 the probe is reusable.
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hysteroscopic evaluation before and after
ablation, in contrast with other nonresectoscopic ablation devices.
 Uterine requirements
 ●Diameter of device 8.5 mm
 ●Sounded cavity length ≥6 to ≤12 cm is
advised by the manufacturer, although the
device was studied in women with a cavity
length of up to 14 cm
 ●Women with submucosal leiomyomas that
do not obstruct treatment access were
included in the studies for FDA approval
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Outcome
A randomized trial compared MEA with
endometrial resection in 263 women
 Excessive intraoperative bleeding occurred in five
women in the resection group and none in the MEA
group
 In women followed for 10 or more years, those
treated with MEA compared with resection had
similar rates of amenorrhea (83 and 88 percent).
 The rate of repeat ablation was similar in women
treated with MEA compared with resection (1
versus 2 percent)
 however, the hysterectomy rate differed significantly
(17 versus 28 percent).
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The manufacturer of MEA advises extra
precautions that are not advised for the
other non-resectoscopic devices:
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including preoperative measurement of the
thickness of the myometrium (, the FDA trial
required that ultrasound be performed prior
to the procedure and that the myometrium
be at least 1 cm in thickness in all areas)
pre- and postoperative hysteroscopy
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Hot liquid filled balloons
ThermaChoice (FDA-approved )
Cavaterm
Thermablate EAS are available only outside the United States
silicon balloon ,inserted through the cervix into the uterine
cavity via a probe
 The balloon is expanded to a pressure of 160 to 220 mmHg
with either 5 percent dextrose in water (ThermaChoice),
glycine (Cavaterm), or glycerine (Thermablate EAS).
 For ThermaChoice and Cavaterm, the fluid is heated to
approximately 68 to 87ºC and ablation requires 8 to 10
minutes.
 Thermablate uses a higher temperature (173ºC) and has
shorter ablation time (two minutes)
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thermachoice
Cryoablation
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liquid nitrogen or by differential gas exchange
An elliptical ice ball approximately 3.5 by 5
centimeters forms around the probe when it is
cooled to less than -90ºC.
At the edge of the ice ball, the tissue temperature is
0ºC, which is nondestructive.
A temperature of –20ºC is lethal to tissue; this
temperature is reached approximately 3 to 5 mm
from the edge of the ice ball. Therefore, the
endometrial tissue exposed to this low temperature,
including the basalis layer of the endometrium is
permanently destroyed.
The number of ice balls that must be
created to destroy the entire uterine
cavity is dependent upon the size of the
cavity.
 Intraoperative ultrasonography is used to
monitor probe placement and depth of
tissue freezing. (two to three ice balls are
sufficient )
 Each freeze cycle takes two to six
minutes
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Uterine requirements — Uterine
parameters for Her Option ablation are:
 ●Diameter of device 5.5 mm
 ●Sounded cavity length ≥4 to ≤10 cm
 ●Women with intramural leiomyomas ≤2
cm in diameter were included in the FDA
approval studies; women with
pedunculated fibroids or endometrial
polyps were excluded
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Endometrial cryoablation
Circulating hot water
(hydrothermal)
which a hysteroscope sheath is inserted into the
uterine cavity under direct hysteroscopic
visualization
 Heated isotonic saline is administered into the
uterus through the sheath. To maintain a low
uterine distension pressure (<70 mmHg), the
fluid is instilled using gravity rather than a pump..
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The treatment phase lasts for 10 minutes, during
which the fluid should be at a temperature of
90ºC.
An intrauterine cool down phase is then
performed for one minute with the fluid at 45ºC
Uterine requirements — Uterine cavity
and cervical dilation parameters for HTA
ablation are :
 ●Diameter of device 7.8 mm
 ●Sounded cavity length ≥6 to ≤10.5 cm
 ●Women with submucosal fibroids were
excluded in the FDA approval studies
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Outcome
A randomized trial compared HTA with rollerball
in 276 women
 Women treated with HTA compared with
rollerball were less likely to have postoperative
hematometra (1 versus 6 percent(
 significantly more likely to experience abdominal
pain (53 versus 38 percent) and postoperative
nausea and vomiting (22 versus 7 percent).
 Two patients in the HTA group had lower
extremity burns due to contact with the device
tubing.
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advantage of this method is that it can be
performed in women with intracavitary
lesions
 is done under direct visualization, so the
operator can ensure that the entire
uterine lining has been destroyed.
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CHOOSING AMONG
TECHNIQUES
●uterine characteristics (cavity size and
the presence of intracavitary lesions)
 ●factors that facilitate use in an office
setting and/or under local anesthesia (eg,
operative duration, perioperative pain)
 ●ease of preoperative preparation
 ●surgeon familiarity and preference
 ●device availability
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Preoperative preparation — Endometrial
preparation is advised by the manufacturer used for
all non-resectoscopic ablation procedures with the
exception of the bipolar radiofrequency device.
The other device manufacturers advise 30 to 60
days of pretreatment with a gonadotropin-releasing
hormone antagonist (eg, intramuscular leuprolide
3.75 mg/month);
preparation for ThermaChoice can be either
hormonal suppression or uterine curettage.
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The duration of energy delivery of the nonresectoscopic endometrial ablation
procedures, from shortest to longest, are:
●Novasure bipolar radiofrequency (90 to
120 seconds)
●MEA (3 to 5 minutes)
●ThermaChoice hot liquid filled balloon (8
minutes)
●HTA circulating hot water (10 minutes)
●Her Option cryoablation (10 minutes).
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Summary — All of the endometrial ablation
devices have similar efficacy and
complication rates and each device has
advantages and disadvantages.
Cryoablation appears to result in the least
patient discomfort.
Bipolar radiofrequency ablation has the
shortest energy delivery time.
Circulating hot water is the only nonresectoscopic method performed using
direct visualization.
Each surgeon should determine which
device is most appropriate in their practice.
Minim Invasive Surg Sci. 2014 May; 3(2): e12431.
Published online 2014 March 30. Research Article
Evaluation of the Success Rate of Endometrial Ablation by CavatermTM
plus
Technique
Zahra Asgari 1; Farideh Hoseinzadeh 1; Aazam Hoseinzadeh 1; Leili Hafizi
2,*
1Department of Obstetrics and Gynecology, Arash Hospital, Faculty of
Medicine, Tehran University of Medical Sciences, Tehran, IR Iran
2Department of Obstetrics and Gynecology, Imam Reza Hospital, Faculty
of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
*Corresponding author: Leili Hafizi, Department of Obstetrics and
Gynecology, Imam Reza Hospital, Faculty of Medicine, Mashhad University
of Medical Sciences, Mashhad, IR Iran.
Tel: +98-5118022608, Fax: +98-5118525305,, E-mail: [email protected]
Received: May 23, 2013; Accepted: April 9, 2014
International Journal of Gynecology and
Obstetrics
Endometrial ablation with the NovaSure system in Iran Zahra Asgari, Ashraf Moini,
Haydeh Samiee, Afsaneh Tehranian, Sima Mozafar-Jalali ⁎, Somayeh Sabet
Department of Gynecology, Arash Hospital, Tehran University of Medical Sciences,
Tehran, Iran article info abstract Article history: Received 5 October 2010
Received in revised form 11 December 2010 Accepted 22 March 2011 Keywords:
Endometrial ablation Hysteroscopy Menorrhagia NovaSure Objective: To evaluate
the rate of response to treatment with the NovaSure endometrial ablation device
among Iranian women with menorrhagia. Methods: Twenty 35–50-year-old women
with menorrhagia who were referred to Arash Hospital, Tehran, Iran, in 2008 were
enrolled. They underwent endometrial ablation via the NovaSure system and were
followed-up for 2 years. Results: The incidence of amenorrhea was 30.0% at the
end of the 2-year follow-up period. Hypomenorrhea was reported by 40.0% of
women. The mean number of days of bleeding per month decreased significantly,
from 30.0± 6.4 days before treatment to 3.1± 2.6 days after 2 years (Pb0.001). The
severity of bleeding decreased significantly within 2 years after treatment
(Pb0.001). In total, 85.0% of women were satisfied and 90.0% had responded to
treatment—as defined by amenorrhea, hypomenorrhea, or return to normal
menstruation. Conclusion: The NovaSure system is effective and should be
considered by gynecologists for the treatment of menorrhagia. © 2011
International Federation of Gynecology and Obstetrics. Published by Elsevier
Ireland Ltd. All rights reserved.