Hysteroscopic Versus Non-Hysteroscopic Ablation Technique

Hysteroscopic Versus Non-Hysteroscopic Ablation Technique

H. Fernandez

South Paris University, Department of Obstetrics and Gynecology

Hפpital Antoine Beclere, Clamart, France

Menorrhagia is a common disorder for many reproductive age women, with significant impact on their medical, social, economic, and psychological well-being. The world-wide prevalence is reported to be high as 19%. This disorder often exists in the absence of organic lesions of the endometrium in the perimenopause.

Traditionnally the first-line treatment is medical in menstruating women. In a randomized study Cooper (1997-1999) showed that medical treatment was less effective than hysteroscopic endometrial resection. Dilatation and curettage is a temporary treatment with limited efficacy and the patient would be better served by hysteroscopic endometrial resection or ablation with Nd Yag laser or electrocoagulation. World-wide experience has demonstrated a 70-90% success rate using hysteroscopic endometrial resection or ablation (Garry, et al., 1995; O’Connor and Magos, 1996). However, hysteroscopic ablation requires additional specialized training and surgical expertise, and involves a significant learning curve. Moreover, serious complications may occur, including fluid overload, uterine perforation, infection, haemorrhage, thermal injuries, and even death. In the Mistlestoe study (Overton, 1997) 10,686 women treated with endometrial ablation performed by 690 different surgeons and by different methods, the complication rate was 4.4%. The Roller-Ball and Nd Yag laser techniques had a lesser complication rate than endometrial resection.

In the interests of overcoming many of these disadvantages and risks, Neuwirth et al. (1994), introduced a thermal uterine balloon therapy system that has been evaluated in several clinical studies of endometrial destruction (Friberb B. et al, 1996 - N.N. Amso et al., 1998). These results indicate that the balloon ablation procedure requires skills similar to those necessary for inserting an intrauterine device. The results obtained withthe uterine balloon are comparable to those previously reported as are those of by hysteroscopic endometrial resection (DeCherney, 1983; Garry et al., 1995; Goldrath, 1995; O’Connor and Magos, 1996). All of these studies demonstrate the efficacy of both methods in the treatment of dysfunctional uterine bleeding in the premenopause. The uterine balloon technique does not require the direct use of endometrial visualisation, distending solutions and high energy sources and it rarely requires cervical dilatation. Minor complications were observed in approximately 3% of cases. In a prospective study we compare clinical efficacy and safety of a thermal uterine balloon system with hysteroscopic endometrial resection. One hundred forty seven women were treated by two experienced gynaecologic surgeons: performed 73 thermal balloon ablations and the other 74 endometrial resections between Novembrer 1994 and April 1998. The inclusion criteria were similar in both groups. The operative time was reduced significantly withthe uterine balloon technique. There were no intraoperative complications. Multivariate analysis noted two prognostic factors associated with failures : retroverted uterus with thermal balloon ablation and age under 43 years with endometrial resection. The overall success rate did not differ significantly between the two groups 83.0±5% for balloon ablation and 76.3±6% for endometrial resection. Meyer et al. (1998) reported a randomized multicenter clinical trial comparing uterine balloon therapy with electrosurgical rollerball ablation. The outcome was similar for both procedures.

Proper patient selection (n=28) permitted us to perform successfully ThermaChoice uterine balloon procedure under local anaesthesia in the outpatient clinic obviating the use of the operating room (Fernandez et al, 1997).

In conclusion, endometrial ablation with thermal balloon is as efficacious as hysteroscopic endometrial resection. The ease of use of the thermal uterine balloon therapy system may allow more gynecologists, especially those who remain untrained or unskilled at operative hysteroscopic surgery, to perform this conservative treatment. The potential of performing the procedure under local anesthesia, the shorter time and the lower rate intraoperative complications (reported in the literature but not in our study) may increase the use of this form of treatment.

References

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