EEndometrial ablation and hysteroscopic myomectomy and polypectomy are having an increasing impact

on the care of women with abnormal uterine bleeding (AUB). The complications of these procedures

include the late onset of recurrent vaginal bleeding, cyclic lower abdominal pain, hematometra and the

inability to adequately sample the endometrium in women with postmenopausal bleeding. According to the

2007 ACOG Practice Bulletin, approximately 24% of women treated with endometrial ablation will undergo

hysterectomy within 4 years.1

By employing careful cervical dilation, a wide variety of gynecologic resectoscopes, and continuous

sonographic guidance it is possible to explore the entire uterine cavity in order to locate areas of

sequestered endometrium, adenomyosis, and occult hematometra.

Sonographically guided reoperative hysteroscopy offers a minimally invasive technique to avoid

hysterectomy in over 60% to 88% of women who experience endometrial ablation failures.2,3 The procedure is

adaptable to an office-based setting and offers a very low incidence of operative complications and

morbidity. In addition, the technique provides a histologic specimen, which is essential in adequately

evaluating the endometrium in postmenopausal women or women at high risk for the development of

adenocarcinoma of the endometrium.

Ultrasound-guided Reoperative Hysteroscopy:

Managing Endometrial Ablation FailuresMORRIS WORTMAN, MD, FACOG

CLINICAL ASSOCIATE PROFESSOR OF GYNECOLOGYUNIVERSITY OF ROCHESTER MEDICAL CENTER

DIRECTOR, CENTER FOR MENSTRUAL DISORDERS AND REPRODUCTIVE CHOICEROCHESTER, NEW YORK

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ABSTRACT

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Endometrial ablation [EA] has beenan important addition to the gynecolog-ic armamentarium for the treatment ofabnormal uterine bleeding. The firsttechniques utilized an operative hys-teroscope in combination with either aneodymnium:YAG laser4 or a surgicalelectrode.5,6 Since 1995, five non-resec-toscopic endometrial ablation (NREA)devices have been introduced andextensively employed to manage AUB inwomen who have completed theirchildbearing.7 Oftentimes, EA is com-bined with hysteroscopic polypectomyor myomectomy to optimize the man-agement of AUB.8

It is well known that of women whoundergo EA a significant number willeventually require a hysterectomy.Longinotti et al. analyzed the long-termresults of 3,681 women undergoingendometrial ablation at 30 Kaiser Per-manente Northern California facilitiesand noted 26% required hysterectomyduring the 8-year follow-up period.9

The ACOG Practice Bulletin, May 2007edition, states that hysterectomy rateswithin 4 years following both resecto-scopic and NREA are at least 24%.1

The late complications of EA arethree-fold: persistent or recurrent vagi-nal bleeding,8 cyclic pelvic pain,9 andthe inability to adequately assess theendometrium in women who laterrequire sampling.10

Troublesome vaginal bleeding, mayoccur months or years following EA andhas been attr ibuted to inadequateendometrial destruction,11,12 unsuspect-ed deep adenomyosis,13 or the occur-rence of new pathology — myomata,endometrial hyperplasia, or cancer.

Pelvic pain is generally cyclic and hasbeen attributed to cornual and centralhematometra10 as well as the post-abla-tion tubal ster ilization syndrome(PATSS).14 McCausland et al. note thatthe etiology of cyclic pelvic pain “fol-lowing both resectoscopic and nonresec-toscopic endometrial ablations is due tothe intrauterine scarring and contracturethat can occur following theprocedure.”10 Hopkins et al. performedhysterosalpingograms on 21 women at3-, 6-, and 9-month intervals followingradiofrequency global endometrial abla-tion and observed that intrauterinesynechiae actually increased throughoutthe observation period suggesting thatthe uterus continues to undergo remod-eling long after the original procedure.15

The inability to adequately assess theuterine cavity is an important andunder-reported delayed complicationfollowing EA. Ahonkallio et al. demon-strated that endometrial biopsies failedin 23% of women with previous EA andwere likely unreliable in many of theremaining patients g iven thatendometrium is often trapped in thecornual region, which is frequentlyinaccessible. Any of these delayed com-plications are sufficient reasons for per-forming hysterectomies.16

Several authors, however, havereported “repeat” or “reoperative”endometrial ablation procedures. In1992, Gimpelson reported a series of 16women who underwent repeat EA uti-lizing either a hysteroscopic Nd:YAG oran electrosurgical technique; all wereable to successfully avoid hysterectomyduring the study period.17 In a series of118 women who were offered reopera-tive hysteroscopic surgery (RHS), Istreet al.18 were successful in avoiding hys-terectomy in 72% of the subjects duringa mean follow-up period of 22 months.In 2001, the author reported a series of26 women who had undergone sono-graphically guided RHS following EAfailures and noted that hysterectomy wasavoided in 88.5% during a mean follow-up period of 23.2 + 22.7 months.3

The author believes that the use of asonographically guided hysteroscopicresection technique provides two distinct

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INTRODUCTION

Figure 1. Three groups of women requiring reoperative hysteroscopic surgery (RHS).

Group 1. Recurrent Vaginal Bleeding

Group 2. Cyclic Pelvic Pain

Group 3. Endometrial sampling because of abnormal perimenopausal or postmenopausal bleeding.

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advantages over other methods of RHS.First, sonographic guidance is an excel-lent tool for locating areas of hematome-tra, endometrial regrowth, andleiomyomas in a setting where standardintrauterine landmarks are often absent.Second, hysteroscopic resection tech-niques provide ample tissue for histolog-ic analysis, an important requirement inthe management of women with a histo-ry of abnormal peri-menopausal or post-menopausal bleeding and a prior EA.This paper will summarize the author’stechnique, which has evolved over thepast two decades and is now performedin an office-based setting.

Indications for ReoperativeHysteroscopic Surgery (RHS)

The indications for RHS fall into thethree groups (Fig. 1) already mentioned:those who experience recurrent vaginalbleeding, (Group 1) cyclic pelvic pain,(Group 2) or require endometrial sam-pling because of abnormal peri-menopausal or postmenopausal bleeding(Group 1). In addition, there is a fourth

group of women who develop asympto-matic hematometra as an incidental find-ing on ultrasound or MRI generallyperformed for another reason. This lat-ter group is usually amenorrheic but mayrequire endometrial sampling dependingon their age and risk factors for develop-ing endometrial cancer.

Preoperative EvaluationThe most important preoperative

tool is a good history. Often the historyis straightforward; a woman with a pre-vious EA presents with graduallyincreasing vaginal bleeding accompaniedby few if any cramps. In other instances,the patient may present with severelower abdominal pain accompanied bylittle or no vaginal bleeding. The painmay be suprapubic or localized to oneof the lower quadrants; it is oftendescribed as suprapubic “sharp,” “stab-bing,” “cramping,” or even “labor-like”in quality. On occasion, the pain may belocalized to the lower back or in one ofthe lower quadrants. When the pain isunaccompanied by vaginal bleeding the

diagnosis is often delayed. In general, thepain will resolve spontaneously within afew days only to recur the next cycle.

A pelvic examination and transvaginalultrasound (TVUS) are best performedwhen the patient is symptomatic. Theformer often reveals uterine tendernesswithout cervical motion or adnexal ten-derness. The latter often reveals thepresence of one or more hematometrae(Fig. 2). In some instances well-circum-scribed areas of endometrium may befound in the cornua (Fig. 3) or scatteredalong the central uterine axis. Addition-ally, ultrasound may be useful in thediagnosis of PATSS. Advanced studiessuch as sonohysterography or hysteros-alpingography are often painful and addlittle to the evaluation.

In determining whether or not pelvicpain is related to a previous EA the use ofendometrial suppressive agents — oralcontraceptives, leuprolide acetate, dana-zol, and medroxyprogesterone — maybe helpful in establishing the diagnosis.The improvement of pelvic pain withendometrial suppression, however, is notspecific to the diagnosis of hematometraor endometrial regrowth. However, thefailure of symptoms to resolve withendometrial suppression strongly sug-gests another etiology.

Who are good candidates forRHS?

Once the diagnosis has been estab-lished several factors must be weighedin determining whether or not thepatient is an appropriate candidate forRHS. Although there is little evidence-based data at this time the authorbelieves that appropriate candidates forRHS include women who meet the cri-teria listed in Table I.

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Figure 2. Transvaginal ultrasound demonstrating hematometra. Figure 3. Transvaginal ultrasound demonstrating endometrial regrowth.

Table ICandidacy for Reoperative Hysteroscopy:

Factors to Consider

A symptom-free interval following the initial EA of at least 1 year

Women who are 45 years of age or older

Uterine dimensions

< 12 cms long, < 6 cms AP, and < 7 cms transverse

Absence of multiple intramural leiomyomas

Absence of severe adenomyosis

Highly motivated women

Subjects are well informed of risks, consequences, and alternatives

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Patient PreparationOnce the decision has been made to

perform RHS, it is best to schedulesurgery in the presence of symptoms orclear ultrasound findings. One shouldrefrain from using endometrial suppres-sive agents during the cycle prior to RHS.

We insist that patients undergoingRHS undergo cervical dilation and lami-nar ia placement the day pr ior tosurgery. This is done under minimal tomoderate sedation. Patients are fore-warned that the evening prior to RHScan be quite uncomfortable as the lami-naria often expands against a fibroticlower uterine segment.

Laminaria placement is preceded bycareful dilation under sonographicguidance with Hegar dilators. General-ly, a 3- or 4-mm laminaria is sufficientfor this purpose and should be passedwell beyond the internal cervical os(Fig. 4). Patients are given prescrip-tions for NSAIDs or opiates and askedto not eat or drink anything prior totheir procedure.

Equipment, Setup, and Personnelfor RHS

The equipment and personnel uti-lized for RHS are identical to what theauthor has reported for sonographicallyguided hysteroscopic endomyometrialresection.19 Low-viscosity fluids aredelivered through one of several fluid-management systems at initial pumpsettings varying from 100 to 180 mmHg. Fluids are allowed to egress bygravity alone during the resection phaseof the procedure. Active suction may besupplied during the coagulation phase inorder to remove as many water vaporbubbles as possible.

Our operating room (Fig. 5) isequipped with an Autocon II 400 (KarlStorz Endoscopy, Culver City, CA)enabling us to utilize both unipolar andbipolar electrosurgery. Unipolar elec-trosurgery is generally performed at140 watts of C-Cut, effect 4, during theresection phase and 120 watts of forcedcoagulation current, effect 4, for theablation portion of the procedure.

Whenever bipolar electrosurgery isused, a saline-C-cut, effect 5, setting isemployed. During unipolar electro-surgery, glycine 1.5% is used for disten-tion; normal saline is used duringbipolar electrosurgery.

Most cases are performed witheither a 22 Fr or a 26 Fr continuousflow resectoscope (CFR), the formerbeing preferred during earlier portionsof the case. A variety of ultrasoundmachines have been used over the pastdecades. We presently use a SiemensAcuson X150 (Siemans Corp., NewYork, NY) equipped with a variable fre-quency abdominal transducer in orderto provide continuous sonographicmonitoring. Our operating room is out-fitted with two side-by-side monitorsthat facilitate real-time observation(Fig. 6). All procedures are digitallyrecorded using a MediCapture USB 200(MediCapture, Inc., Philadelphia, PA).

Most cases are presently performedin an office setting and require a mini-mum of 4 assistants. The first assistant

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Figure 6. Operating room with monitors side by side. Figure 7. New Igor drawing of ultrasound-guided reoperative hysteroscopicsurgery.

Figure 4. Laminaria japonica placed under ultrasound guidance. Figure 5. Operating room setup.

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stands to the operator’s left while thesonographer stands to the right. A fluidmanagement technician is responsiblefor all functions related to the hys-teroscopy pump and reports the rate offluid absorption as well as the net fluiddeficit. The fourth member of the teamis an appropriately trained and creden-tialed registered nurse who administersmidazolam and fentanyl while monitor-ing the patient for her level of conscious-ness.

PROCEDURE

The procedure is begun by removingthe previously placed laminaria andprepping the cervix and vagina with abactericidal solution. The cervix isgrasped at 12 o’clock with a tenaculum.Next, a vasopressin solution containing2.5 units in 20 mL saline is injecteddeep into the cervical stroma at 3 and 9o’clock using a 21-gauge x 1½-inchneedle. The cervix is carefully dilatedunder sonographic guidance to either 8mm (for a 22 Fr CFR) or 10 mm (for a26 Fr CFR). Glycine 1.5% is deliveredat a pump infusion pressure of 120 to180 mm Hg. We carefully monitor fluidabsorption and adjust the infusion pres-sure accordingly. In the presence of asmall or tubular cavity the initial resec-tion is carried out on the thickest uter-ine wall, which is often the posterior oranterior wall. Even in the presence ofpoor hysteroscopic visualization thisfirst critical strip is removed by extend-ing the loop approximately 7 mm andremoving a continuous ribbon of tissuefrom the upper reaches of the cavity tothe internal os, a maneuver performed

almost entirely with ultrasound guid-ance (Fig. 7). In most cases, the removalof this tissue strip provides sufficientroom within the uterine cavity so thatcontinuous flow and visualization arefacilitated. Once this central cavity isestablished the resection margin iswidened in all quadrants with care toleave at least 5 mm to 10 mm of tissuefrom the central cavity to the uterineserosa at any given point. It is importantto keep the uterine cavity well distend-ed allowing an adequate “sonohystero-gram” during the procedure. This isdone by maintaining sufficient pumppressure and minimizing extravasationof fluid from the cervix; the latter canbe accomplished by placing additionaltenaculae at the 3 or 9 o’clock positions(Fig. 8). Unlike endomyometrial resec-tion (EMR),20 there is no predeter-mined order of resection. Each case is

highly variable, and the particular pathof dissection is determined by both theintrauterine and sonographic findings,the two complementing each other.

Initial inspection of the cavity mayreveal active endometrial elements. Insome cases, islands of endometrium arehemosiderin-stained, especially if thearea has been contained within asequestered hematometra. The extentof intrauterine adhesions (IUA) can bequite variable. In some instances thereare few, if any, IUA — this is especiallytrue when RHS is offered to womenwho have received little relief of theirmenstrual symptoms and in whom new-onset cyclic pelvic pain is not a majorpresenting problem. In other clinicalscenarios, initial inspection reveals vir-tually no endometrial elements; this isespecially true if there is a sequesteredarea of endometrium or a hematometra.

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Figure 8. Two-tenaculae technique.

Figure 9. Igor drawing of centrally located hematometra. Figure 10. Reconfigured loop electrode.

PROCEDURE

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Oftentimes, ultrasound guidance is ableto determine the relationship betweenthe resectoscope loop and thehematometra. In this scenario it isimportant that only thin strips of tissuebe removed (1 to 3 mm in thickness).The management of centrally locatedhematometra (Fig. 9) is fairly straight-forward, and RHS can be managedmuch like a primary EMR.20 In mostcases of RHS the tubal ostia are notclearly identified. Should one fail toidentify the tubal ostia it is important tocarefully explore the cornua. This canbe done with a reconfigured loop elec-trode (Fig. 10) with care to performboth blunt and electrosurgical dissectionunder scrupulous sonographic guidance.Cautious dissection often allows theoperator entry into a cornualhematometra — often signaled by theegress of chocolaty material — beyondwhich active endometrial elements areclearly seen (Figs. 11a & 11b). Once thesurgeon is confident that all remainingareas of endometrium have been identi-

fied and excised, the freshly exposedmyometrium is then deeply coagulatedwith a ball-electrode, usually at 120watts of coagulation current. The finalresult generally reveals a cavity, which isquite larger than originally noted (Fig.12); a transabdominal scan confirms theextent of dissection and the disappear-ance of any preoperative evidence of ahematometra.

CONCLUSIONS

Although the precise number of alltypes of endometr ial ablation andresection performed in the UnitedStates is difficult to uncover, one esti-mate suggests that in 2008 alone,approximately 312,000 global endome-trial ablations were performed in thiscountry.21 Longinotti et al. noted thatin a cohort of 3,681 women with a his-tory of EA the probability of subse-quent hysterectomy at 8 years was

26%, the majority of which were donewithin 3 years of the original proce-dure.9 The failure rate appears to beunrelated to the type of procedure orthe existence of leiomyomas. Age at thetime of the original procedure appearsto play an important role in predictinghysterectomy risk. Women under theage of 40 have a 40% probability ofhysterectomy during the 8-year follow-up period, while the risk drops to 20%for women in the 45 to 50 year agecohort. The results were similar for alltypes of EA procedures and indepen-dent of leiomyomata.

Longinotti et al. also note that themost common indications were vaginalbleeding (51.6%), pain (22%), andvaginal bleeding with pain (20.3%).9

Although there are relatively few seriesof RHS for EA failures the available datasuggest that between 60% to 88.5% ofhysterectomies can be avoided inwomen followed up to 84 months.2,3,18

The author’s experience suggeststhat the incorporation of careful patient

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Figure 12ab Cavity before RHS.

a b

Figures 11a and 11b. Dissection of cornual hematometra.

a b

CONCLUSIONS

Figure 12b. Cavity after RHS

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selection, meticulous cervical prepara-tion, and sonographic guidance are thekeys to performing safe reoperative hys-teroscopy with a high degree of patientsatisfaction and success. The assembly ofa dedicated and stable operating roomteam is a key component for this proce-dure’s success. Future work is neededto better delineate those women whoare the best candidates for reoperativehysteroscopic surgery.

AUTHOR’S DISCLOSURES

The author is a consultant for Holog-ic, Inc. However, they will not be fund-ing any of this work. There are nopertinent conflicts of interest.

REFERENCES

1. Munro MG. ACOG Practice Bulletin:endometrial ablation. Obstet Gynecol2007;109:1233–47.2. Hansen BB, Dreisler E, Sorensen SS. Out-come of repeated hysteroscopic resection ofthe endometrium. J Minim Invasive Gynecol

2008;15:704–6.3. Wortman M, Daggett A. Reoperative hys-teroscopic surgery in the management ofpatients who fail endometrial ablation andresection. J Am Assoc Gynecol Laparosc2001;8:272–7.4. Loffer FD. Hysteroscopic endometrialablation with the Nd:YAG laser using a non-touch technique. Obstet Gynecol 1987;679–82.5. Magos AL, Baumann R, Lockwood GM, etal. Experience with the first 250 endometrialresections for menorrhagia. Lancet 1991;337:1074–8.6. Vancaillie TG. Electrocoagulation of theendometrium with the ball-end resectoscope.Obstet Gynecol 1989;74:425–7.7. Zarek S, Sharp H. Global endometrialablation devices. Clin Obstet Gynecol2008;51: 167–75.8. Loffer FD. Improving results of hystero-scopic submucosal myomectomy for menor-rhagia by concomitant endometrial ablation. JMinim Invasive Gynecol 2005;3:254–60.9. Longinotti MK, Jacobson G, Hung Y, etal. Probability of hysterectomy after endome-trial ablation. Obstet Gynecol 2008;112:1214–20.10. McCausland AM, McCausland VM.Long-term complications of minimally inva-sive endometrial ablation devices. J GynecolSurg 2010;26:133–49.11. Turnbull LW, Jumaa A, Bowsley SJ, etal. A magnetic resonance imaging of theuterus after endometrial resection. British J

Obstet Gynecol 1997;104:934–8.12. Lisa JR, Gio JD, Rubin IC. Observationson the interstitial portion of the fallopiantube. Surg Gynecol Obstet 1954;92:159–69.13. McCausland AM, McCausland VM.Depth of endometrial penetration in adeno-myosis helps determine outcome of rollerballablation. Am J Obstet Gynecol 1996;174:1786–93.14. Townsend DE, McCausland VM, McCaus-land AM. Post-ablation-tubal sterilization syn-drome. Obstet Gynecol 1993;82: 422–4.15. Hopkins MR, Creedon DJ. Radiofre-quency global endometrial ablation followedby hysteroscopic sterilization. J Minim Inva-sive Gynecol 2007;14:494–501.16. Ahonkallio SJ, Liakka AK, MartikainenHK, et al. Feasibility of endometrial assess-ment after thermal ablation. Eur J ObstetGynecol Reprod Biol 2009;147:69–71.17. Gimpelson RJ, Kaigh J. Endometrial abla-tion repeat procedures case studies. J ReproMed 1992;37:629–34.18. Istre O, Langebrekke A. Repeat hystero-scopic surgery reduces the hysterectomy rateafter endometrial and myoma resection. J AmAssoc Gynecol Laparosc 2003;10:247–51.19. Wortman M. Sonographically guided hys-teroscopic endomyometrial resection. SurgTech Int 2011;XXI:163–9. 20. Wortman M, Daggett A. Hysteroscopicendomyometrial resection. JSLS 2000;4:197–207.21. http://investors.hologic.com/ index.php?s=43&item=420. Queried August 5, 2012.

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STI

AUTHOR’S DISCLOSURES