#424 Wortman FINAL Gynecology SURGICAL TECHNOLOGY INTERNATIONAL XXII Ultrasound-guided Reoperative Hysteroscopy: Managing Endometrial Ablation Failures MORRIS WORTMAN, MD, FACOG CLINICAL ASSOCIATE PROFESSOR OF GYNECOLOGY UNIVERSITY OF ROCHESTER MEDICAL CENTER DIRECTOR, CENTER FOR MENSTRUAL DISORDERS AND REPRODUCTIVE CHOICE ROCHESTER, NEW YORK ABSTRACT ndometrial 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 Einclude 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. - 1 - #424 Wortman FINAL Ultrasound-guided Reoperative Hysteroscopy: Managing Endometrial Ablation Failures WORTMAN INTRODUCTION It is well known that of women who Troublesome vaginal bleeding, may undergo EA a significant number will occur months or years following EA and eventually require a hysterectomy. has been attributed to inadequate Endometrial ablation [EA] has been Longinotti et al. analyzed the long-term endometrial destruction,11,12 unsuspect- an important addition to the gynecolog- results of 3,681 women undergoing ed deep adenomyosis,13 or the occur- ic armamentarium for the treatment of endometrial ablation at 30 Kaiser Per- rence of new pathology — myomata, abnormal uterine bleeding. The first manente Northern California facilities endometrial hyperplasia, or cancer. techniques utilized an operative hys- and noted 26% required hysterectomy Pelvic pain is generally cyclic and has teroscope in combination with either a during the 8-year follow-up period.9 been attributed to cornual and central neodymnium:YAG laser4 or a surgical The ACOG Practice Bulletin, May 2007 hematometra10 as well as the post-abla- electrode.5,6 Since 1995, five non-resec- edition, states that hysterectomy rates tion tubal sterilization syndrome toscopic endometrial ablation (NREA) within 4 years following both resecto- (PATSS).14 McCausland et al. note that devices have been introduced and scopic and NREA are at least 24%.1 the etiology of cyclic pelvic pain “fol- extensively employed to manage AUB in The late complications of EA are lowing both resectoscopic and nonresec- women who have completed their three-fold: persistent or recurrent vagi- toscopic endometrial ablations is due to childbearing.7 Oftentimes, EA is com- nal bleeding,8 cyclic pelvic pain,9 and the intrauterine scarring and contracture bined with hysteroscopic polypectomy the inability to adequately assess the that can occur following the or myomectomy to optimize the man- endometrium in women who later procedure.”10 Hopkins et al. performed agement of AUB.8 require sampling.10 hysterosalpingograms on 21 women at 3-, 6-, and 9-month intervals following radiofrequency global endometrial abla- tion and observed that intrauterine synechiae actually increased throughout the observation period suggesting that the uterus continues to undergo remod- eling long after the original procedure.15 The inability to adequately assess the uterine cavity is an important and under-reported delayed complication following EA. Ahonkallio et al. demon- strated that endometrial biopsies failed Group 1. Recurrent Vaginal Bleeding in 23% of women with previous EA and were likely unreliable in many of the remaining patients given that endometrium is often trapped in the cornual region, which is frequently inaccessible. Any of these delayed com- plications are sufficient reasons for per- forming hysterectomies.16 Several authors, however, have reported “repeat” or “reoperative” endometrial ablation procedures. In 1992, Gimpelson reported a series of 16 women who underwent repeat EA uti- Group 2. Cyclic Pelvic Pain lizing either a hysteroscopic Nd:YAG or an electrosurgical technique; all were able to successfully avoid hysterectomy during the study period.17 In a series of 118 women who were offered reopera- tive hysteroscopic surgery (RHS), Istre et al.18 were successful in avoiding hys- terectomy in 72% of the subjects during a mean follow-up period of 22 months. In 2001, the author reported a series of 26 women who had undergone sono- graphically guided RHS following EA failures and noted that hysterectomy was avoided in 88.5% during a mean follow- Group 3. Endometrial sampling because 3 of abnormal perimenopausal or postmenopausal bleeding. up period of 23.2 + 22.7 months. The author believes that the use of a sonographically guided hysteroscopic Figure 1. Three groups of women requiring reoperative hysteroscopic surgery (RHS). resection technique provides two distinct - 2 - #424 Wortman FINAL Gynecology SURGICAL TECHNOLOGY INTERNATIONAL XXII Figure 2. Transvaginal ultrasound demonstrating hematometra. Figure 3. Transvaginal ultrasound demonstrating endometrial regrowth. advantages over other methods of RHS. group of women who develop asympto- diagnosis is often delayed. In general, the First, sonographic guidance is an excel- matic hematometra as an incidental find- pain will resolve spontaneously within a lent tool for locating areas of hematome- ing on ultrasound or MRI generally few days only to recur the next cycle. tra, endometrial regrowth, and performed for another reason. This lat- A pelvic examination and transvaginal leiomyomas in a setting where standard ter group is usually amenorrheic but may ultrasound (TVUS) are best performed intrauterine landmarks are often absent. require endometrial sampling depending when the patient is symptomatic. The Second, hysteroscopic resection tech- on their age and risk factors for develop- former often reveals uterine tenderness niques provide ample tissue for histolog- ing endometrial cancer. without cervical motion or adnexal ten- ic analysis, an important requirement in derness. The latter often reveals the the management of women with a histo- Preoperative Evaluation presence of one or more hematometrae ry of abnormal peri-menopausal or post- The most important preoperative (Fig. 2). In some instances well-circum- menopausal bleeding and a prior EA. tool is a good history. Often the history scribed areas of endometrium may be This paper will summarize the author’s is straightforward; a woman with a pre- found in the cornua (Fig. 3) or scattered technique, which has evolved over the vious EA presents with gradually along the central uterine axis. Addition- past two decades and is now performed increasing vaginal bleeding accompanied ally, ultrasound may be useful in the in an office-based setting. by few if any cramps. In other instances, diagnosis of PATSS. Advanced studies the patient may present with severe such as sonohysterography or hysteros- Indications for Reoperative lower abdominal pain accompanied by alpingography are often painful and add Hysteroscopic Surgery (RHS) little or no vaginal bleeding. The pain little to the evaluation. The indications for RHS fall into the may be suprapubic or localized to one In determining whether or not pelvic three groups (Fig. 1) already mentioned: of the lower quadrants; it is often pain is related to a previous EA the use of those who experience recurrent vaginal described as suprapubic “sharp,” “stab- endometrial suppressive agents — oral bleeding, (Group 1) cyclic pelvic pain, bing,” “cramping,” or even “labor-like” contraceptives, leuprolide acetate, dana- (Group 2) or require endometrial sam- in quality. On occasion, the pain may be zol, and medroxyprogesterone — may pling because of abnormal peri- localized to the lower back or in one of be helpful in establishing the diagnosis. menopausal or postmenopausal bleeding the lower quadrants. When the pain is The improvement of pelvic pain with (Group 1). In addition, there is a fourth unaccompanied by vaginal bleeding the endometrial suppression, however, is not specific to the diagnosis of hematometra Table I or endometrial regrowth. However, the failure of symptoms to resolve with Candidacy for Reoperative Hysteroscopy: endometrial suppression strongly sug- Factors to Consider gests another etiology. A symptom-free interval following the initial EA of at least 1 year Who are good candidates for Women who are 45 years of age or older RHS? Once the diagnosis has been estab- Uterine dimensions lished several factors must be weighed < 12 cms long, < 6 cms AP, and < 7 cms transverse in determining whether or not the Absence of multiple intramural leiomyomas patient is an appropriate candidate for RHS. Although there is little evidence- Absence of severe adenomyosis based data at this time