Hysteroscopy: Managing and minimizing operative complications
Techniques to assess the site, spot imminent perforation, and avoid or correct the 5 most common types of problems.
The use of bipolar devices in normal saline prevents dilutional hyponatremia, but fluid deficits must still be monitored electronically so they do not exceed 2,000 mL. The false sense of security that may occur when normal saline is used for distention may lead to inaction when a large deficit occurs. This can lead to pulmonary edema and death.
Postoperative and late complications
These include infection, endometrial cancer, iatrogenic adenomyosis, hematometria, post-ablation tubal ligation syndrome, and pregnancy.
Infection rate is 0.3% to 2%
Infection is relatively rare following endometrial ablation, with a rate of 0.3% to 0.5% reported in most series. Endometritis, parametritis, and pyometra are more common following resection of submucous myomas, with rates as high as 2% reported.
Infection is more likely after prolonged procedures, especially when the hysteroscope is repeatedly inserted and removed. It also is more likely if the patient has a history of pelvic inflammatory disease. I generally administer prophylactic antibiotics (1 dose of intravenous ceftizoxime, 1 g, approximately 30 to 60 minutes prior to surgery).
I also insert a laminaria tent the evening prior to surgery. Patients with a history of pelvic inflammatory disease are discharged on doxycycline (100 mg twice daily for 7 days).
Be alert for endometrial cancer
This malignancy has been diagnosed at the time of endometrial ablation and reported in patients who have undergone prior endometrial ablations or fibroid resections. Thus, endometrial sampling should be part of the workup of abnormal uterine bleeding before the patient is scheduled for operative hysteroscopy. In women at high risk for endometrial cancer, perform office diagnostic hysteroscopy, with directed biopsy of any suspicious areas.
When viable endometrial glands are “buried” during ablation, or synechiae develop, preventing the egress of blood, there is a chance that diagnosis of endometrial cancer will be delayed. However, this theoretical fear has not been proven clinically.
Patients whose abnormal bleeding recurs after ablation should undergo sampling and office hysteroscopy, just as if they had not undergone a previous ablation. Theoretically, women who undergo endomyometrial resection or vaporization should have a lower incidence of endometrial cancer, since the tissue most susceptible to malignancy is removed. This has not yet been proven scientifically.
In their comprehensive review of late complications of operative hysteroscopy, Cooper and Brady21 suggest that patients at high risk for endometrial cancer who present with abnormal uterine bleeding not controlled by hormones might be better served by hysterectomy. Unfortunately, these patients tend to be high-risk surgical candidates.
If atypia is present, do not perform endometrial ablation or resection. I do perform ablation and resection in patients with complex hyperplasia without atypia if it has been reversed with progestin and does not recur for at least 6 months without progestin therapy. These patients undergo office hysteroscopy and sampling of the endometrium before operative hysteroscopy is scheduled.
Iatrogenic adenomyosis
Two theories suggest this is a late complication of operative hysteroscopy. According to the first, when the endometrium is incompletely resected, scarring over this tissue causes the viable glands to grow into the myometrium. The other theory suggests that viable endometrial debris is transported into the myometrium by vessels opened at resection.
I have found that using the vaporization electrode followed by application of a rollerball over the surface of the cavity most effectively reaches maximal tissue depth and, theoretically, prevents adenomyosis. Since most adenomyosis occurs on the posterior wall, I take a strip from this area for pathologic analysis to determine whether adenomyosis preceded the ablation or developed subsequent to it.
Hematometria
This can occur following operative hysteroscopy if viable glands are left in the fundal or cornual region and synechiae develop in the lower segment, preventing egress of blood. It also can occur if the upper endocervix is ablated and subsequently scars, causing stenosis. To avoid this, ablate only to the level of the internal os.
Diagnosis and treatment. Hematometria can be diagnosed easily by ultrasound and treated with office hysteroscopy using a narrow-diameter, rigid, continuous-flow hysteroscope with an operating channel to pass small instruments.
Post-ablation tubal ligation syndrome
This is cornual hematometria that develops when viable endometrial cells are left in the cornua when the cavity also contains synechiae, causing cyclic bleeding. Since there is no egress from the cervix or tubes, blood gradually builds up, leading to hematosalpinx and pain. One way to avoid this is to ensure complete ablation of the cornual endometrium.
Prevention. Some experts recommend that the small rollerball electrode be placed in the cornua, with slightly reduced intrauterine pressure, to allow the cornual endometrium to collapse around the rollerball. A short burst of current is then applied to ablate the tissue.
