Transcript Endometrial Ablation Techniques

Bilgin GURATES, M.D.
Abnormal Uterine Bleeding
Causes of abnormal uterine bleeding
Current treatment options for abnormal
uterine bleeding
 MEDICAL THERAPY
 Levonorgestrel intra-uterine system (LNGIUS),
The levonorgestrel-releasing
 Non-steroidal anti-inflammatory
drugs,
intrauterine system is more effective,
 Antifibrinolytic drugs,and has been shown to
as effective
at be
best,
oral
as endometrial ablation.
medication
 Progestogens,
reduces menstrual
endometrial
 Oral contraceptives It could be argued that
blood
loss
surgery is only appropriate
for50%
those
by only
 Danazol
women who are not suitable (i.e.polyps,
fibroids) or for women who do not wish
to have treatment with the intrauterine
system.
Current treatment options for abnormal
uterine bleeding
 SURGICAL THERAPY
 ENDOMETRIAL RESECTION/ABLATION
 HYSTERECTOMY
 OTHER
The idea of destroying the
 Myomecyomy
endometrium and creating an
 Polypectomy
iatrogenic ‘Asherman’s syndrome’
 .......................
as a treatment for dysfunctional
bleeding.
Inclusion and exclusion criteria for endometrial ablation
Endometrial Ablation Techniques
 First-generation endometrial ablation: hysteroscope
 Loop (Hallez in 1985)
 Roller-ball (DeCherney and Polan in 1983)
 Laser(Goldrath in 1981)
 Second-generation endometrial ablation: non-hysteroscopic
 Hot liquid balloons(Cavaterm, ThermaChoice, Menotreat)
 Microwave
 Hydro Therm Ablator(BEI, Enabl)
 Cryotherapy (Her Option, Soprano)
 Electrode: mesh – NovaSure
 Laser interstitial hyperthermy
 Photodynamic therapy
First-generation endometrial ablation:
 Loop
 Roller-ball
 Laser
 effective and safe
 alternatives to hysterectomy
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dysfunctional uterine bleeding
reduction in menstrual blood loss
dysmenorrhoea,
correction of anaemia
improvement in quality of life.
lower morbidity,
shorter hospitalisation and faster recovery,
reduced treatment costs.
As a result, the 1st generation ablation techniques are recognized
as the ‘‘gold standard’’ ablation methods.
First-generation endometrial ablation:
 All these techniques are aimed at
 normalising menorrhagia,
 making periods lighter,
 shorter and
 less painful;
 amenorrhoea can not be achieved reliably by any
ablation technique, and
 hysterectomy remains the only realistic option even now
if this endpoint is desired.
Different strategies for endometrial preparations prior to
first-generation ablation
Equipment for hysteroscopic endometrial ablation
Loop endometrial resection
 Advantages
 Provides endometrial tissue for histology
 Suitable if endometrium is thick
 Submucous fibroids or polyps can be excised at the same
time
 Disadvantages
 The most skill dependent of the three techniques
 Greatest risk of uterine perforation
 Need to use electrolyte free distension media (with
monopolar resectoscope)
Rollerball endometrial ablation
 Advantages
 Easier to learn and perform than resection
 Less risk of uterine perforation, fluid absorption and
haemorrhage than endometrial resection
 Shorter operating time than laser ablation
 Disadvantages
 No endometrial specimen for histology
 Cannot treat submucous fibroids (unless using rollerbar
or barrel)
 Use of monopolar energy which is less safe than bipolar
 Need to use non-physiologic distension media
Endometrial laser ablation
 Advantages
 Tissue coagulation to 5–6 mm
 Perforation less likely than resection
 Small fibroids or polyps can be vaporised
 Disadvantages
 Expensive capital and running costs
 Slowest of all the techniques
 Greater risk of fluid overload than with electrosurgery
 Need for special laser safety procedures and guidelines
COMPARATIVE STUDIES OF HYSTEROSCOPIC
ENDOMETRIAL ABLATION
fluid
overload
uterine
perforation
amenorrhoea
failure
rate
subsequently
undergoing
hysterectomy
satisfaction
rates
repeat
ablation
Laser
ablation
5.1%
0.65%
56%
7%,
5%
93%
11%
Loop
resection
1.5%
2.47%
48%
6-30%
9%
70 to
94%
6%
Roller-ball
ablation
1.2%
2.1%
10%
5.5%
90%
16.4%
46%
The most important determinant of the success and safety of hysteroscopic
methods of endometrial ablation is not the technique per se but the experience
of the operator.
Second-generation endometrial ablation:
 Hot liquid balloons(Cavaterm, ThermaChoice,
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Menotreat)
Microwave
Hydro Therm Ablator(BEI, Enabl)
Cryotherapy (Her Option, Soprano)
Electrode: mesh – NovaSure
Laser interstitial hyperthermy (ELITT Gynelase)
Photodynamic therapy
Hot liquid balloons
 The advantages of the
ThermaChoice balloon device
include portability, ease of use,
and short learning curve.
 The small-diameter catheter
requires minimal cervical
dilatation (5 mm) and allows
treatment under minimal
analgesia/anesthesia
requirements, including no
local anesthesia or IV sedation.
The HydroThermAblator
 Disadvantages of the HTA system
include cervical dilatation to 8mm,
the requirement for pretreatment,
reduced portability, the need for
hysteroscopic equipment and
potential thermal burns.
Microwave endometrial ablation
 The system consists of an 8-
mm diameter reusable probe
which is inserted into the
uterus.
 Microwaves are short highfrequency radio waves. They
are part of the
electromagnetic spectrum
with a wavelength of 0.3–30
cm and a frequency of 300–
300 000 MHz.
Novasure
 The Novasure endometrial ablation
system consists of a single-use device
and a radiofrequency controller.
 It is a three-dimensional, triangularshaped bipolar ablation device.
 cerival dilatation to 7.5 mm
Endometrial cryoablation
 The Her Option In-Office
Cryoablation Therapy system is ideal
for in-office procedures. The unique
analgesic properties of cryotherapy,
small-diameter probe size, and the
ease of use make it appropriate for
use in an office setting.
 This cryosurgical system is
compressor driven and uses a new
mixed gas coolant to generate
temperatures of –90° to –100°C.
THIRD-GENERATION ENDOMETRIAL
ABLATION TECHNOLOGIES
 The idea of injecting a gel or solution via a small-
diameter catheter, to destroy the endometrium
globally in an office setting, using no analgesia, is so
attractive that several such agents are currently
undergoing feasibility and safety evaluation.
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