Diagnosis and treatment of global endometrial ablation failure

January 6, 2017|ObGyn

Correcting late-onset failures

Our office-based operating room is fitted with side-by-side monitors that enable simultaneous sonographic and hysteroscopic views for correction of GEA failures; the rest of the set-up is similar to that of other operative hysteroscopies. However, we do employ a wide variety of resectoscopes with diameters ranging from 13 to 28 Fr. The smaller-diameter scopes are particularly useful for evaluating postmenopausal bleeding in women with a prior EA.

In this view, the posterior endocervical strip has been removed beginning just above the internal os. Hemosiderin stained tissue can be seen anteriorly at the apex of the dissection.

Nearly all patients are seen the day before surgery for placement of a laminaria. The cervix is dilated 3-4 mm with the adjuvant use of IV sedation and sonographic guidance that combines sagittal and transverse scanning to ensure placement of the laminaria in the midline. This preparatory work provides an easily identifiable channel – the next day – that extends past the internal os.

For those inexperienced with ultrasound-guided surgery, the initial resection is often the most challenging. The initial tissue removal is carried out on the thickest observed uterine wall – usually the posterior or anterior wall – and is done with near complete reliance on the ultrasound image. Hysteroscopic visualization is poor at this time because the outflow ports of the continuous flow resectoscope are obstructed by tissue in the narrow tubular cavity.

This image shows that the central hematometra has been entered and drained. Viable and functioning endometrial tissue can be seen at the fundus.

The loop is advanced approximately 7-8 mm, and a strip of tissue from the upper reaches of the cavity to the internal os is removed as the entire resectoscope and loop assembly are maneuvered together and withdrawn. A full-size resectoscope loop will resect no more than 4 mm of depth and thus poses no risk of compromising the integrity of the uterus. The thickest wall should be no less than 12-15 mm thick until one masters this technique.

We then actually remove the resectoscope and clean the outflow ports of clots and debris that may have accumulated. When the scope is reinserted, there is typically sufficient room in the uterine cavity for continuous flow and excellent hysteroscopic visualization.

The sequence of resection from this point on will vary. If we’ve begun on the anterior wall, we’ll move to the posterior and then the two lateral walls to further restore the cavity. Areas of endometrial regrowth will typically be identified at this point and resected. The dissection then will extend upward, usually to within 10 mm of the fundus in the midline as measured by ultrasound. Reconfiguring the loop electrode to a 135- to 160-degree angle can be helpful in the delicate dissection that is required at the fundus.

In this view, both cornua have now been explored and active endometrial tissue can be observed in the midline at the fundus.

Once the upper limit of dissection is established, we sweep laterally using both ultrasound and hysteroscopic visualization. We commonly dissect tissue in and around the cornua, and we often identify intramural fibroids and sometimes gross areas of adenomyosis as we explore the entire uterus. Sonography is critically important as we work in the uterine cornua; our sonographer switches frequently between sagittal and transverse views.

Once all areas of endometrium have been identified and excised, we will deeply coagulate exposed myometrium with a ball-end electrode. Rarely, we will reach our maximum allowable fluid absorption limit prior to completing the case, a scenario seen in less than 1% of our patients.

In more than 330 reoperative hysteroscopic procedures, we’ve had only one uterine perforation that occurred when we switched ultrasound machines. Very likely, we were too aggressive in removing tissue at the fundus. The patient required a diagnostic laparoscopy but sustained no visceral injury.

Dr. Wortman is a clinical associate professor of obstetrics and gynecology at the University of Rochester (N.Y.) and the director of the Center for Menstrual Disorders and Reproductive Choice in Rochester. He reported having no relevant financial disclosures.